Healthcare Provider Details

I. General information

NPI: 1104113588
Provider Name (Legal Business Name): HOLLY ANNE HENGGELER PHARM D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 07/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 S MAIN ST
PAYETTE ID
83661-3317
US

IV. Provider business mailing address

405 SOUTH 8TH STREET
PAYETTE ID
83661
US

V. Phone/Fax

Practice location:
  • Phone: 208-642-9331
  • Fax: 208-642-1550
Mailing address:
  • Phone: 208-642-9331
  • Fax: 208-642-1550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP5513
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: