Healthcare Provider Details

I. General information

NPI: 1346646155
Provider Name (Legal Business Name): HOLLY GEFROH-GRIMES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2014
Last Update Date: 11/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 S GRAND AVE
SUN PRAIRIE WI
53590-9832
US

IV. Provider business mailing address

660 S GRAND AVE
SUN PRAIRIE WI
53590-9832
US

V. Phone/Fax

Practice location:
  • Phone: 608-834-5601
  • Fax: 608-834-5611
Mailing address:
  • Phone: 608-834-5601
  • Fax: 608-834-5611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17676-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: