Provider Demographics
NPI:1902143522
Name:HOLLIS, ANNETTE YVONNE
Entity Type:Individual
Prefix:MISS
First Name:ANNETTE
Middle Name:YVONNE
Last Name:HOLLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 E SHELBY DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38118-7256
Mailing Address - Country:US
Mailing Address - Phone:901-900-4502
Mailing Address - Fax:
Practice Address - Street 1:3333 E SHELBY DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-7256
Practice Address - Country:US
Practice Address - Phone:901-900-4502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000038926183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4442531Medicaid