Provider Demographics
NPI:1831104447
Name:HOLT PHARMACY SERVICES, LLC
Entity Type:Organization
Organization Name:HOLT PHARMACY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAYSON
Authorized Official - Middle Name:B
Authorized Official - Last Name:BULMAHN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:716-471-8067
Mailing Address - Street 1:2018 CEDAR ST STE A
Mailing Address - Street 2:
Mailing Address - City:HOLT
Mailing Address - State:MI
Mailing Address - Zip Code:48842-1400
Mailing Address - Country:US
Mailing Address - Phone:517-694-9707
Mailing Address - Fax:517-694-9713
Practice Address - Street 1:2018 CEDAR ST STE A
Practice Address - Street 2:
Practice Address - City:HOLT
Practice Address - State:MI
Practice Address - Zip Code:48842-1400
Practice Address - Country:US
Practice Address - Phone:517-694-9707
Practice Address - Fax:517-694-9713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010074393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2363062OtherNCPDP
MI2363062Medicaid
BH7517165OtherDEA
4269240001Medicare ID - Type Unspecified