Healthcare Provider Details

I. General information

NPI: 1881642296
Provider Name (Legal Business Name): PATRICK S HOGAN RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12000 STONE LAKE ROAD JICARILLA SERVICE UNIT
DULCE NM
87528
US

IV. Provider business mailing address

HC 75 BX 66
CHAMA NM
87520
US

V. Phone/Fax

Practice location:
  • Phone: 575-759-7250
  • Fax: 575-759-7288
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number30013
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: