Provider Demographics
NPI:1417356320
Name:HOLLY STREET DRUGS LLC
Entity Type:Organization
Organization Name:HOLLY STREET DRUGS LLC
Other - Org Name:HOLLY HILL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PRESIDENT, PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OSTEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-496-0007
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:HOLLY HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29059-0370
Mailing Address - Country:US
Mailing Address - Phone:803-496-0007
Mailing Address - Fax:803-496-0015
Practice Address - Street 1:904 HOLLY ST
Practice Address - Street 2:
Practice Address - City:HOLLY HILL
Practice Address - State:SC
Practice Address - Zip Code:29059-0370
Practice Address - Country:US
Practice Address - Phone:803-496-0007
Practice Address - Fax:803-496-0015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-15
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SC153233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2147870OtherPK
SC7153235Medicaid