=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194390203
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID NATHAN HOLBROOK PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2021
-----------------------------------------------------
Last Update Date | 05/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6 S. MAIN ST
-----------------------------------------------------
City | GRACE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-425-3766
-----------------------------------------------------
Fax | 208-425-9010
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 325
-----------------------------------------------------
City | GRACE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83241-0325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-425-3766
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | P7251
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------