Provider Demographics
NPI:1386083939
Name:HOGAN, STANLEY LAMAR (BSRPH)
Entity type:Individual
Prefix:MR
First Name:STANLEY
Middle Name:LAMAR
Last Name:HOGAN
Suffix:
Gender:M
Credentials:BSRPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:299 JAMES MOORE CIR
Mailing Address - Street 2:P O BOX 125
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-2421
Mailing Address - Country:US
Mailing Address - Phone:770-775-3663
Mailing Address - Fax:770-775-1279
Practice Address - Street 1:4 2ND ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233-1920
Practice Address - Country:US
Practice Address - Phone:770-775-3663
Practice Address - Fax:770-775-1279
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH011320183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00029807AMedicaid