1861544868 NPI number — NORTHWEST SYNERGY INC

Table of content: (NPI 1861544868)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861544868 NPI number — NORTHWEST SYNERGY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST SYNERGY 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:
COMMUNITY DRUG OF INTERLOCHEN
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:
1861544868
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2100 OLD GRADE AVE.
Provider Second Line Business Mailing Address:
BOX 67
Provider Business Mailing Address City Name:
INTERLOCHEN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-276-9014
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 OLD GRADE AVE.
Provider Second Line Business Practice Location Address:
BOX 67
Provider Business Practice Location Address City Name:
INTERLOCHEN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-276-9014
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MACRAE
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
ANDREWS
Authorized Official Title or Position:
CO OWNER
Authorized Official Telephone Number:
231-352-4471

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  5301006774 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2317382 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2317382 . This is a "NABP" identifier . This identifiers is of the category "OTHER".




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