Provider Demographics
NPI:1982912333
Name:COLBERT, HOLLY ELIZABETH
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:ELIZABETH
Last Name:COLBERT
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 1:107 N MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:MS
Mailing Address - Zip Code:39730-2635
Mailing Address - Country:US
Mailing Address - Phone:662-369-0060
Mailing Address - Fax:662-369-6324
Practice Address - Street 1:107 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:MS
Practice Address - Zip Code:39730-2635
Practice Address - Country:US
Practice Address - Phone:662-369-0060
Practice Address - Fax:662-369-6324
Is Sole Proprietor?:No
Enumeration Date:2010-09-20
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE08926183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00330311Medicaid