Provider Demographics
NPI:1932700622
Name:HOLDEN, BETHANY MARIE
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:MARIE
Last Name:HOLDEN
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 1:19211 467TH AVE
Mailing Address - Street 2:
Mailing Address - City:ESTELLINE
Mailing Address - State:SD
Mailing Address - Zip Code:57234-5648
Mailing Address - Country:US
Mailing Address - Phone:605-691-1899
Mailing Address - Fax:
Practice Address - Street 1:1201 29TH ST SE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-9179
Practice Address - Country:US
Practice Address - Phone:605-886-8419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-08
Last Update Date:2020-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD54753336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy