Provider Demographics
NPI:1396987186
Name:BROGAN, JENNIFER L (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:BROGAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3243 W 115TH ST
Mailing Address - Street 2:
Mailing Address - City:MERRIONETTE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60803-4555
Mailing Address - Country:US
Mailing Address - Phone:708-597-4828
Mailing Address - Fax:708-597-8957
Practice Address - Street 1:3243 W 115TH ST
Practice Address - Street 2:
Practice Address - City:MERRIONETTE PARK
Practice Address - State:IL
Practice Address - Zip Code:60803-4555
Practice Address - Country:US
Practice Address - Phone:708-597-4828
Practice Address - Fax:708-597-8957
Is Sole Proprietor?:No
Enumeration Date:2009-03-25
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051291892183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363168270102Medicaid
IL363168270102Medicaid