Provider Demographics
NPI:1568822021
Name:HOLLEY PHARMACY INC
Entity type:Organization
Organization Name:HOLLEY PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT/PIC/AO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:334-393-0086
Mailing Address - Street 1:612 N MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-1775
Mailing Address - Country:US
Mailing Address - Phone:334-393-0086
Mailing Address - Fax:334-393-0206
Practice Address - Street 1:612 N MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-1775
Practice Address - Country:US
Practice Address - Phone:334-393-0086
Practice Address - Fax:334-393-0206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-26
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336M0002X
AL1145913336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL183049Medicaid
2158301OtherPK