Provider Demographics
NPI:1558482000
Name:HOLTS PHARMACY INC
Entity Type:Organization
Organization Name:HOLTS PHARMACY INC
Other - Org Name:HOLTS PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:770-382-5757
Mailing Address - Street 1:406 GRASSDALE RD
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30121-1975
Mailing Address - Country:US
Mailing Address - Phone:770-382-5757
Mailing Address - Fax:770-382-6757
Practice Address - Street 1:406 GRASSDALE RD
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30121-1975
Practice Address - Country:US
Practice Address - Phone:770-382-5757
Practice Address - Fax:770-382-6757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0058593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00305885AMedicaid
1125120OtherNCPDP PROVIDER IDENTIFICATION NUMBER