Basic Information
Provider Information | |||||||||
NPI: | 1316517253 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOLBROOK | ||||||||
FirstName: | RALPH | ||||||||
MiddleName: | EEWARD | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | R.PH | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2252 SW 10TH AVE | ||||||||
Address2: |   | ||||||||
City: | TOPEKA | ||||||||
State: | KS | ||||||||
PostalCode: | 666043965 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7852358796 | ||||||||
FaxNumber: | 7852351939 | ||||||||
Practice Location | |||||||||
Address1: | 2252 SW 10TH AVE | ||||||||
Address2: |   | ||||||||
City: | TOPEKA | ||||||||
State: | KS | ||||||||
PostalCode: | 666043965 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7852358796 | ||||||||
FaxNumber: | 7852351939 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/01/2021 | ||||||||
LastUpdateDate: | 07/01/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P2201X | 1-09291 | KS | Y |   |   |   |   |
ID Information
ID | Type | State | Issuer | Description | 1-09291 | 01 | KS | PHARMACY REGISTRATION NUMBER | OTHER |