Provider Demographics
NPI:1346646155
Name:GEFROH-GRIMES, HOLLY
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:GEFROH-GRIMES
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 1:660 S GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-9832
Mailing Address - Country:US
Mailing Address - Phone:608-834-5601
Mailing Address - Fax:608-834-5611
Practice Address - Street 1:660 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-9832
Practice Address - Country:US
Practice Address - Phone:608-834-5601
Practice Address - Fax:608-834-5611
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17676-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist