# A.G. HOLLEY STATE HOSPITAL

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1295811032
- **Authorized official:** MS. JERRY JEAN STAMBAUGH RPH (PHARMACIST)
- **Authorized official phone:** (561) 540-3721

## Contact information

- **Practice address:** 1199 LANTANA RD, LANTANA, FL 33462-1514
- **Practice address phone:** (561) 540-3721
- **Practice address fax:** (561) 545-0372
- **Mailing address:** 1199 LANTANA RD, LANTANA, FL 33462-1514
- **Mailing address phone:** (561) 540-3721
- **Mailing address fax:** (561) 545-0372

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 3336I0012X | Institutional Pharmacy | PH0016562 | FL | Yes |

## Other

- **Enumeration date:** 10/27/2006
- **Last updated:** 06/13/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 0215171-00 | — | FL |