Provider Demographics
NPI:1760468367
Name:HOLMAN, SUSAN K (RPH)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:K
Last Name:HOLMAN
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 1:610 HARVEY CT
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-2101
Mailing Address - Country:US
Mailing Address - Phone:573-756-4239
Mailing Address - Fax:
Practice Address - Street 1:60A NESBIT DR
Practice Address - Street 2:
Practice Address - City:BONNE TERRE
Practice Address - State:MO
Practice Address - Zip Code:63628-1368
Practice Address - Country:US
Practice Address - Phone:573-358-3301
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO040715183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1047440002Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER