Provider Demographics
NPI:1851458871
Name:HOLTAN, HALEY SUZANNE (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:HALEY
Middle Name:SUZANNE
Last Name:HOLTAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:HALEY
Other - Middle Name:SUZANNE
Other - Last Name:EVERETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:701 PARK AVENUE
Mailing Address - Street 2:RL
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415
Mailing Address - Country:US
Mailing Address - Phone:612-873-7462
Mailing Address - Fax:612-904-4260
Practice Address - Street 1:701 PARK AVENUE
Practice Address - Street 2:RL
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415
Practice Address - Country:US
Practice Address - Phone:612-873-7462
Practice Address - Fax:612-904-4260
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118554183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN313973000Medicaid