Provider Demographics
NPI:1982119053
Name:HOLLIS, NICKI MARIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:NICKI
Middle Name:MARIE
Last Name:HOLLIS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2135 N WEST AVE
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-3351
Mailing Address - Country:US
Mailing Address - Phone:870-862-5458
Mailing Address - Fax:
Practice Address - Street 1:2135 N WEST AVE
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-3351
Practice Address - Country:US
Practice Address - Phone:870-862-5458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-11
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD14058183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPD14058OtherARKANSAS STATE BOARD OF PHARMACY
479466OtherNABP