Healthcare Provider Details

I. General information

NPI: 1881915957
Provider Name (Legal Business Name): HOLLADAY PHARMACEUTICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2010
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 N STATE ST
OREM UT
84057-3802
US

IV. Provider business mailing address

69 E HUDSON DR
ELK RIDGE UT
84651-5598
US

V. Phone/Fax

Practice location:
  • Phone: 801-434-7670
  • Fax: 801-434-7669
Mailing address:
  • Phone: 801-434-7670
  • Fax: 801-434-7669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number7686605-1703
License Number StateUT

VIII. Authorized Official

Name: PENNY JO GUSTAFSON
Title or Position: MANAGER
Credential:
Phone: 801-756-4021