Provider Demographics
NPI:1972159614
Name:PATTILLO, JAN HOLLEY (RPH)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:HOLLEY
Last Name:PATTILLO
Suffix:
Gender:F
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 112
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:TX
Mailing Address - Zip Code:76531-0112
Mailing Address - Country:US
Mailing Address - Phone:254-386-3111
Mailing Address - Fax:254-386-8844
Practice Address - Street 1:107 N RICE ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:TX
Practice Address - Zip Code:76531-1857
Practice Address - Country:US
Practice Address - Phone:254-386-3111
Practice Address - Fax:254-386-8844
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX28590183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1578660411OtherNARCFACTS