=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659971471
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HOLLIE LOVELL PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2020
-----------------------------------------------------
Last Update Date | 10/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 OZARK DR
-----------------------------------------------------
City | CUBA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65453-1664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-885-2501
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 506 E SPRUCE ST
-----------------------------------------------------
City | CHATHAM
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62629-1629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-477-2847
-----------------------------------------------------
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 | 2020029178
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------