MEDICARE: HOLIDAY PROFESSIONAL PHARMACY INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy	100	ND

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922000108
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLIDAY PROFESSIONAL PHARMACY INC.

Provider Business Mailing Address
First Line	:	1140 E BISMARCK EXPY
Second Line	:
City	:	BISMARCK
State	:	ND
Zip	:	58504-6603
Country	:	US
Telephone Number	:	701-255-7220
Fax Number	:	701-255-6029

Provider Business Practice Location Address
First Line	:	1140 E BISMARCK EXPY
Second Line	:
City	:	BISMARCK
State	:	ND
Zip	:	58504-6603
Country	:	US
Telephone Number	:	701-255-7220
Fax Number	:	701-255-6029

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JERRY RIXEN
Credential	:	R.PH.
Telephone Number	:	701-255-7220

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	08/22/2020

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