Provider Demographics
NPI:1053386847
Name:HOLYCROSS, JEFFREY L
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:L
Last Name:HOLYCROSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8200 STATE ROUTE 366
Mailing Address - Street 2:
Mailing Address - City:RUSSELLS POINT
Mailing Address - State:OH
Mailing Address - Zip Code:43348
Mailing Address - Country:US
Mailing Address - Phone:937-843-3700
Mailing Address - Fax:973-843-2801
Practice Address - Street 1:8200 STATE ROUTE 366
Practice Address - Street 2:
Practice Address - City:RUSSELLS POINT
Practice Address - State:OH
Practice Address - Zip Code:43348-9670
Practice Address - Country:US
Practice Address - Phone:937-843-3700
Practice Address - Fax:973-843-2801
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-2-12762183500000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0577666Medicaid
OH0577666Medicaid