1093719783 NPI number — EDWARD W. SPARROW HOSPITAL ASSOCIATION

Table of content: (NPI 1093719783)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093719783 NPI number — EDWARD W. SPARROW HOSPITAL ASSOCIATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDWARD W. SPARROW HOSPITAL ASSOCIATION
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:
SPARROW PHARMACY PLUS CARSON
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:
1093719783
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3301 E MICHIGAN AVE STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48912-4641
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-253-6310
Provider Business Mailing Address Fax Number:
517-253-6315

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
245 S 2ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARSON CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48811-9650
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-584-3272
Provider Business Practice Location Address Fax Number:
989-584-0541
Provider Enumeration Date:
06/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PRATT
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATIVE DIRECTOR
Authorized Official Telephone Number:
517-253-6313

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: 5301004178 , 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: 2338728 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1093719783 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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