Provider Demographics
NPI:1538142583
Name:HOGAN, KERRY SHANE (PHARM D)
Entity Type:Individual
Prefix:MR
First Name:KERRY
Middle Name:SHANE
Last Name:HOGAN
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 CARTER AVE
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-1201
Mailing Address - Country:US
Mailing Address - Phone:641-682-3313
Mailing Address - Fax:
Practice Address - Street 1:1131 N QUINCY AVE
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-3857
Practice Address - Country:US
Practice Address - Phone:641-683-3814
Practice Address - Fax:641-682-3687
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19763183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist