1780689026 NPI number — NORTHGATE PHARMACY INC.

Table of content: (NPI 1780689026)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780689026 NPI number — NORTHGATE PHARMACY INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHGATE PHARMACY INC.
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:
NORTHGATE PHARMACY
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:
1780689026
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
114 S HURON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARBOR BEACH
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48441-1201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-479-3241
Provider Business Mailing Address Fax Number:
989-479-3242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
721 N VAN DYKE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAD AXE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48413-9188
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-269-8061
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/14/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RAYL
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
989-269-8061

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 333600000X , with the licence number: 5301007690 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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