Provider Demographics
NPI:1902026552
Name:DEWANE, HOLLY EDNA (RPH)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:EDNA
Last Name:DEWANE
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 1:1650 S 41ST ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-7316
Mailing Address - Country:US
Mailing Address - Phone:920-320-4400
Mailing Address - Fax:920-320-5104
Practice Address - Street 1:1650 S 41ST ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-7316
Practice Address - Country:US
Practice Address - Phone:920-320-4400
Practice Address - Fax:920-320-5104
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12697-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist