Provider Demographics
NPI:1235776261
Name:HOLMGREN, IVANNA
Entity Type:Individual
Prefix:
First Name:IVANNA
Middle Name:
Last Name:HOLMGREN
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 1:96076 LOFTON SQUARE CT
Mailing Address - Street 2:
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097-6347
Mailing Address - Country:US
Mailing Address - Phone:904-261-6500
Mailing Address - Fax:904-261-1009
Practice Address - Street 1:96076 LOFTON SQUARE CT
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-6347
Practice Address - Country:US
Practice Address - Phone:904-261-6500
Practice Address - Fax:904-261-1009
Is Sole Proprietor?:No
Enumeration Date:2019-12-10
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS55079183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist