Provider Demographics
NPI:1083210694
Name:HOLMES, STEPHANIE LADALE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LADALE
Last Name:HOLMES
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 1:505 20TH ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-1510
Mailing Address - Country:US
Mailing Address - Phone:304-522-1035
Mailing Address - Fax:304-525-8239
Practice Address - Street 1:505 20TH ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25703-1510
Practice Address - Country:US
Practice Address - Phone:304-522-1035
Practice Address - Fax:345-525-8239
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03135956183500000X
WVRP0009698183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist