Provider Demographics
NPI:1063652584
Name:HOLIDAY RX INC
Entity Type:Organization
Organization Name:HOLIDAY RX INC
Other - Org Name:HOLIDAY RX INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:KATSUOCUZAKAO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-738-9881
Mailing Address - Street 1:4143 VIA MARINA APT 819
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-5306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:303 E BASELINE RD
Practice Address - Street 2:103
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-6530
Practice Address - Country:US
Practice Address - Phone:602-276-5821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-24
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY0050953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0355962OtherNCPDP PROVIDER IDENTIFICATION NUMBER