Provider Demographics
NPI:1497063952
Name:HOLLY, ELIZABETH DAWN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:DAWN
Last Name:HOLLY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 HIGHWAY 25 S
Mailing Address - Street 2:
Mailing Address - City:IUKA
Mailing Address - State:MS
Mailing Address - Zip Code:38852-1314
Mailing Address - Country:US
Mailing Address - Phone:662-423-3676
Mailing Address - Fax:662-423-5703
Practice Address - Street 1:615 HIGHWAY 25 S
Practice Address - Street 2:
Practice Address - City:IUKA
Practice Address - State:MS
Practice Address - Zip Code:38852-1314
Practice Address - Country:US
Practice Address - Phone:662-423-3676
Practice Address - Fax:662-423-5703
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-18
Last Update Date:2010-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE 6177183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist