Provider Demographics
NPI:1881915957
Name:HOLLADAY PHARMACEUTICAL LLC
Entity type:Organization
Organization Name:HOLLADAY PHARMACEUTICAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-756-4021
Mailing Address - Street 1:69 E HUDSON DR
Mailing Address - Street 2:
Mailing Address - City:ELK RIDGE
Mailing Address - State:UT
Mailing Address - Zip Code:84651-5598
Mailing Address - Country:US
Mailing Address - Phone:801-434-7670
Mailing Address - Fax:801-434-7669
Practice Address - Street 1:406 N STATE ST
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-3802
Practice Address - Country:US
Practice Address - Phone:801-434-7670
Practice Address - Fax:801-434-7669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-11
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
UT7686605-17033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2125523OtherPK
UT1881915957Medicaid