Provider Demographics
NPI:1275172249
Name:HOLMQUIST, JON J
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:J
Last Name:HOLMQUIST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2655
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-2601
Mailing Address - Country:US
Mailing Address - Phone:208-720-4352
Mailing Address - Fax:208-727-8304
Practice Address - Street 1:100 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:208-727-8300
Practice Address - Fax:208-727-8304
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-23
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4861183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist