Provider Demographics
NPI:1285234229
Name:SHOULTZ, HOLLY (RPH)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:SHOULTZ
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4058 E COUNTY ROAD 475 N
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47567-8964
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 S STATE ROAD 57
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IN
Practice Address - Zip Code:47501-4541
Practice Address - Country:US
Practice Address - Phone:812-254-6195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26018457A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist