1134560345 NPI number — THE PRESCRIPTION SHOP OF GLEN ARBOR, INC

Table of content: (NPI 1134560345)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134560345 NPI number — THE PRESCRIPTION SHOP OF GLEN ARBOR, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE PRESCRIPTION SHOP OF GLEN ARBOR, 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:
Provider Other Organization Name Type Code:
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:
1134560345
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6404 WESTERN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLEN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49636-5101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-334-6608
Provider Business Mailing Address Fax Number:
231-334-6610

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6404 WESTERN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLEN ARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49636-5101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-334-6608
Provider Business Practice Location Address Fax Number:
231-334-6610
Provider Enumeration Date:
07/16/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BOCK
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
231-943-0600

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  5301006252 , 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)





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