Provider Demographics
NPI:1487953816
Name:HOLLAND, JERRY T JR (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:T
Last Name:HOLLAND
Suffix:JR
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 YELLOWSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4433
Mailing Address - Country:US
Mailing Address - Phone:208-239-4033
Mailing Address - Fax:208-239-4027
Practice Address - Street 1:800 YELLOWSTONE AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4433
Practice Address - Country:US
Practice Address - Phone:208-239-4033
Practice Address - Fax:208-239-4027
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-24
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5677183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist