Provider Demographics
NPI:1679573364
Name:HOLTZ, MICHAEL A (RPH)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:A
Last Name:HOLTZ
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12923 CANAL VIEW DR
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49348-9222
Mailing Address - Country:US
Mailing Address - Phone:269-792-3790
Mailing Address - Fax:
Practice Address - Street 1:71 124TH AVE
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:MI
Practice Address - Zip Code:49344-9772
Practice Address - Country:US
Practice Address - Phone:269-672-7774
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302032772183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302032772OtherPHARMACIST LICENSE
MI5302032772OtherCONTROLLED SUBSTANCE LICE