1902914377 NPI number — PONTIAC TRAIL PHARMACY INC

Table of content: (NPI 1902914377)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902914377 NPI number — PONTIAC TRAIL PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PONTIAC TRAIL 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:
PONTIAC TRAIL MEDICAL 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:
1902914377
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
43155 W. NINE MILE RD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NOVI
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48376-8026
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:
620 N. PONTIAC TRAIL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLED LAKE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48390
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-669-2776
Provider Business Practice Location Address Fax Number:
248-669-2835
Provider Enumeration Date:
08/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HENDRICKS
Authorized Official First Name:
CARL
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
OWNER/R.PH.
Authorized Official Telephone Number:
248-669-2776

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 5301004197 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2338689 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1665835 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1649484 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2338689 . This is a "OTHER ID NUMBER" identifier . This identifiers is of the category "OTHER".




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