Healthcare Provider Details

I. General information

NPI: 1689670275
Provider Name (Legal Business Name): HOLLY S DIVINE PHARM.D
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 ROSE STREET
LEXINGTON KY
40536-0082
US

IV. Provider business mailing address

627 REGENT RD
VERSAILLES KY
40383-1637
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-9332
  • Fax:
Mailing address:
  • Phone: 859-873-4021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11548
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: