Provider Demographics
NPI:1881642296
Name:HOGAN, PATRICK S (RPH)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:S
Last Name:HOGAN
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:HC 75 BX 66
Mailing Address - Street 2:
Mailing Address - City:CHAMA
Mailing Address - State:NM
Mailing Address - Zip Code:87520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12000 STONE LAKE ROAD
Practice Address - Street 2:JICARILLA SERVICE UNIT
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528
Practice Address - Country:US
Practice Address - Phone:575-759-7250
Practice Address - Fax:575-759-7288
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO30013183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000K3526Medicaid
NMHSZ196OtherMEDICARE PART B
NM320057Medicare Oscar/Certification