1073504619 NPI number — LISA K URBANC PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073504619 NPI number — LISA K URBANC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LISA K URBANC PC
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:
NORTHERN MENOMINEE 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:
1073504619
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 155
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPALDING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49886-0155
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:
N 16088 US 2- 41
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPALDING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49886-0155
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-497-5516
Provider Business Practice Location Address Fax Number:
906-497-4206
Provider Enumeration Date:
11/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
URBANC
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
906-497-5516

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 5301005133 , 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: 2344757 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2344757 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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