Provider Demographics
NPI:1902474695
Name:COBB, HOLLY ANN
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:ANN
Last Name:COBB
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 1:111 E SAGINAW ST
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-2737
Mailing Address - Country:US
Mailing Address - Phone:517-333-0825
Mailing Address - Fax:
Practice Address - Street 1:111 E SAGINAW ST
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-2737
Practice Address - Country:US
Practice Address - Phone:517-333-0825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303004861183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician