Provider Demographics
NPI:1336170935
Name:BROGDON, JOSEPH CLYDE (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:CLYDE
Last Name:BROGDON
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 1:110 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:GA
Mailing Address - Zip Code:31635-1116
Mailing Address - Country:US
Mailing Address - Phone:229-482-3677
Mailing Address - Fax:229-482-2072
Practice Address - Street 1:110 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:GA
Practice Address - Zip Code:31635-1116
Practice Address - Country:US
Practice Address - Phone:229-482-3677
Practice Address - Fax:229-482-2072
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10831183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10831OtherPHARMACY LICENSE #