Provider Demographics
NPI:1790269827
Name:FOGAN, DEDE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DEDE
Middle Name:
Last Name:FOGAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13517 RED EGRET DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78729-8098
Mailing Address - Country:US
Mailing Address - Phone:864-640-7864
Mailing Address - Fax:
Practice Address - Street 1:13517 RED EGRET DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78729-8098
Practice Address - Country:US
Practice Address - Phone:864-640-7864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-25
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX60133183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist