1578602520 NPI number — HACKLEY PROFESSIONAL PHARMACY

Table of content: (NPI 1578602520)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578602520 NPI number — HACKLEY PROFESSIONAL PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HACKLEY PROFESSIONAL PHARMACY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HACKLEY PHARMACY WHITEHALL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578602520
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
905 E COLBY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITEHALL
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49461-1262
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
905 E COLBY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITEHALL
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49461-1262
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-728-5974
Provider Business Practice Location Address Fax Number:
231-728-1604
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOSSE
Authorized Official First Name:
CARLTON
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PHARMACY
Authorized Official Telephone Number:
231-728-5974

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 1852218 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2369153 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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