Provider Demographics
NPI:1003210402
Name:HOLISTIC PHARMACY SERVICE INC
Entity Type:Organization
Organization Name:HOLISTIC PHARMACY SERVICE INC
Other - Org Name:MEDICINE SHOPPE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BEAUX
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:217-525-0058
Mailing Address - Street 1:133 N GRAND AVE E
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-3859
Mailing Address - Country:US
Mailing Address - Phone:217-525-0058
Mailing Address - Fax:217-525-0034
Practice Address - Street 1:133 N GRAND AVE E
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-3859
Practice Address - Country:US
Practice Address - Phone:217-525-0058
Practice Address - Fax:217-525-0034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-14
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054.017739333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy