Provider Demographics
NPI:1013125012
Name:HOLDER, LARRY EUGENE (RPH)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:EUGENE
Last Name:HOLDER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-3312
Mailing Address - Country:US
Mailing Address - Phone:601-442-7611
Mailing Address - Fax:601-442-0664
Practice Address - Street 1:636 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-3312
Practice Address - Country:US
Practice Address - Phone:601-442-7611
Practice Address - Fax:601-442-0664
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS01732011183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2501268OtherNABP#
MS00035122Medicaid
MS1528170529OtherPHARMACY NPI#