Provider Demographics
NPI:1003208117
Name:HOLSTINE, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:HOLSTINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 S CLAY AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:LIBERAL
Mailing Address - State:KS
Mailing Address - Zip Code:67901-4448
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 W 15TH ST
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-2445
Practice Address - Country:US
Practice Address - Phone:620-624-5334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-10756183500000X
IL051292395183500000X
OH03216663183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist