Provider Demographics
NPI:1508838327
Name:LANE, DONALD KEITH (RPH)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:KEITH
Last Name:LANE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 250
Mailing Address - Street 2:112 SOUTH DOOLY STREET
Mailing Address - City:MONTEZUMA
Mailing Address - State:GA
Mailing Address - Zip Code:31063-0250
Mailing Address - Country:US
Mailing Address - Phone:478-472-7561
Mailing Address - Fax:478-472-5887
Practice Address - Street 1:112 S DOOLY ST
Practice Address - Street 2:
Practice Address - City:MONTEZUMA
Practice Address - State:GA
Practice Address - Zip Code:31063-1604
Practice Address - Country:US
Practice Address - Phone:478-472-7561
Practice Address - Fax:478-472-5887
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH013836183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1112527OtherNCPDP
GA00927649AMedicaid
GARPH013836OtherPHARMACIST LICENSE
GADEA REGISTRATIONOtherBM7599814
GA00927649AMedicaid