Provider Demographics
NPI:1396369302
Name:HOLLER, CODY A (PHARMD)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:A
Last Name:HOLLER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9487 W GOLFVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-7958
Mailing Address - Country:US
Mailing Address - Phone:708-305-3715
Mailing Address - Fax:
Practice Address - Street 1:655 MAIN ST NW
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2303
Practice Address - Country:US
Practice Address - Phone:815-929-0590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26028639A183500000X
IL051303007183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist