Provider Demographics
NPI:1649575036
Name:MANTOOTH, HOLLY M (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:M
Last Name:MANTOOTH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 WOODWAY DR
Mailing Address - Street 2:
Mailing Address - City:BLOUNTVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37617-5558
Mailing Address - Country:US
Mailing Address - Phone:423-323-3047
Mailing Address - Fax:423-844-2897
Practice Address - Street 1:1 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7430
Practice Address - Country:US
Practice Address - Phone:423-844-2855
Practice Address - Fax:423-844-2897
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-17
Last Update Date:2011-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9074183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist