Provider Demographics
NPI:1578815916
Name:HOLT, DAVID WAYNE (RPH)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WAYNE
Last Name:HOLT
Suffix:
Gender:M
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:PO BOX 932
Mailing Address - Street 2:
Mailing Address - City:WALDPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97394-0932
Mailing Address - Country:US
Mailing Address - Phone:541-563-6444
Mailing Address - Fax:541-563-6448
Practice Address - Street 1:110 SW HIGHWAY 101
Practice Address - Street 2:
Practice Address - City:WALDPORT
Practice Address - State:OR
Practice Address - Zip Code:97394-3035
Practice Address - Country:US
Practice Address - Phone:541-563-6444
Practice Address - Fax:541-563-6448
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7509183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist