=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376191726
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES HOLLIS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2019
-----------------------------------------------------
Last Update Date | 02/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 845 S SUB STATION RD
-----------------------------------------------------
City | EMMETT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83617-9430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-369-4510
-----------------------------------------------------
Fax | 208-369-4546
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 845 S SUB STATION RD
-----------------------------------------------------
City | EMMETT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83617-9430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-369-4510
-----------------------------------------------------
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 | P8421
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------