Provider Demographics
NPI:1134465701
Name:GOLLY, LANCE M
Entity Type:Individual
Prefix:MR
First Name:LANCE
Middle Name:M
Last Name:GOLLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 AGENCY ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52601-1993
Mailing Address - Country:US
Mailing Address - Phone:319-758-9991
Mailing Address - Fax:319-758-9989
Practice Address - Street 1:3245 AGENCY ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52601-1993
Practice Address - Country:US
Practice Address - Phone:319-758-9991
Practice Address - Fax:319-758-9989
Is Sole Proprietor?:No
Enumeration Date:2012-12-29
Last Update Date:2012-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA17685183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist