Provider Demographics
NPI:1821419458
Name:HOLM, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:HOLM
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 1:121 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOLON
Mailing Address - State:IA
Mailing Address - Zip Code:52333-9500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:121 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SOLON
Practice Address - State:IA
Practice Address - Zip Code:52333-9500
Practice Address - Country:US
Practice Address - Phone:319-621-0252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-28
Last Update Date:2013-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19192183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA19192OtherPHARMACY LICENSE NUMBER