Provider Demographics
NPI:1922000108
Name:HOLIDAY PROFESSIONAL PHARMACY INC.
Entity Type:Organization
Organization Name:HOLIDAY PROFESSIONAL PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:RIXEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:701-255-7220
Mailing Address - Street 1:1140 E BISMARCK EXPY
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-6603
Mailing Address - Country:US
Mailing Address - Phone:701-255-7220
Mailing Address - Fax:701-255-6029
Practice Address - Street 1:1140 E BISMARCK EXPY
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-6603
Practice Address - Country:US
Practice Address - Phone:701-255-7220
Practice Address - Fax:701-255-6029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND100333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND20680Medicaid
ND20680Medicaid