Provider Demographics
NPI:1992255681
Name:JUCKETT, HOLLY (PHARMD)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:JUCKETT
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 1:4200 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-2137
Mailing Address - Country:US
Mailing Address - Phone:248-738-7810
Mailing Address - Fax:
Practice Address - Street 1:4200 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-2137
Practice Address - Country:US
Practice Address - Phone:248-738-7810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302041585183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist