1194805234 NPI number — THE APOTHECARY SHOPPE PHARMACIES, LLC

Table of content: (NPI 1194805234)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194805234 NPI number — THE APOTHECARY SHOPPE PHARMACIES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE APOTHECARY SHOPPE PHARMACIES, LLC
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:
6
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:
1194805234
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1727
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDLAND
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48641-1727
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-313-3677
Provider Business Mailing Address Fax Number:
866-582-3636

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
244 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDLAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48640-5114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-835-3636
Provider Business Practice Location Address Fax Number:
989-832-6160
Provider Enumeration Date:
10/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GARDNER
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
P
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
800-313-3677

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 5301007440 , 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: 540E610610 . This is a "BSBC DME" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2363050 . This is a "NCPDP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 502363050 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 874717710 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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