Provider Demographics
NPI:1275816357
Name:HOLSTED, WILLARD DEAN (PHARMACIST)
Entity Type:Individual
Prefix:DR
First Name:WILLARD
Middle Name:DEAN
Last Name:HOLSTED
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 RIDGECREST DR
Mailing Address - Street 2:
Mailing Address - City:EL RENO
Mailing Address - State:OK
Mailing Address - Zip Code:73036-5600
Mailing Address - Country:US
Mailing Address - Phone:405-295-6575
Mailing Address - Fax:
Practice Address - Street 1:1506 RIDGECREST DR
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-5600
Practice Address - Country:US
Practice Address - Phone:405-295-6575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-24
Last Update Date:2011-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7497183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist