Provider Demographics
NPI:1295811032
Name:A.G. HOLLEY STATE HOSPITAL
Entity type:Organization
Organization Name:A.G. HOLLEY STATE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MS
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:STAMBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:561-540-3721
Mailing Address - Street 1:1199 LANTANA RD
Mailing Address - Street 2:
Mailing Address - City:LANTANA
Mailing Address - State:FL
Mailing Address - Zip Code:33462-1514
Mailing Address - Country:US
Mailing Address - Phone:561-540-3721
Mailing Address - Fax:561-545-0372
Practice Address - Street 1:1199 LANTANA RD
Practice Address - Street 2:
Practice Address - City:LANTANA
Practice Address - State:FL
Practice Address - Zip Code:33462-1514
Practice Address - Country:US
Practice Address - Phone:561-540-3721
Practice Address - Fax:561-545-0372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH00165623336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0215171-00Medicaid