Healthcare Provider Details

I. General information

NPI: 1063853547
Provider Name (Legal Business Name): HOLT'S PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2013
Last Update Date: 03/17/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 W 1180 N STE 12
TOOELE UT
84074-1483
US

IV. Provider business mailing address

134 W 1180 NORTH STE 12
TOOELE UT
84074
US

V. Phone/Fax

Practice location:
  • Phone: 435-249-0767
  • Fax: 435-249-0754
Mailing address:
  • Phone: 435-249-0767
  • Fax: 435-249-0754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1063853547
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name: REBECCA CHRISTINE HOLT
Title or Position: PRESIDENT/PHARMACIST
Credential:
Phone: 435-249-0767