=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477968147
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOLT PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2014
-----------------------------------------------------
Last Update Date | 07/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2291 CEDAR ST
-----------------------------------------------------
City | HOLT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48842-1202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-699-1544
-----------------------------------------------------
Fax | 517-699-1588
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2291 CEDAR ST
-----------------------------------------------------
City | HOLT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48842-1202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-699-1544
-----------------------------------------------------
Fax | 517-699-1588
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, PIC
-----------------------------------------------------
Name | AMNA KHAN
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 517-699-1544
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 5301010487
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------