Provider Demographics
NPI:1790564680
Name:HARTZOG, SCOTT (RPH)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:
Last Name:HARTZOG
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 1:111 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:DONALSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:39845-1601
Mailing Address - Country:US
Mailing Address - Phone:229-524-2223
Mailing Address - Fax:
Practice Address - Street 1:111 E 2ND ST
Practice Address - Street 2:
Practice Address - City:DONALSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:39845-1601
Practice Address - Country:US
Practice Address - Phone:229-524-2223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA16494183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist