1235315979 NPI number — PH COPPER COUNTRY APOTHECARIES LLC

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 1235315979 NPI number — PH COPPER COUNTRY APOTHECARIES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PH COPPER COUNTRY APOTHECARIES 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:
1235315979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
894 CAMPUS DR STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HANCOCK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49930-1644
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-483-1290
Provider Business Mailing Address Fax Number:
906-483-1291

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
894 CAMPUS DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
HANCOCK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49930-1644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-483-1290
Provider Business Practice Location Address Fax Number:
906-483-1291
Provider Enumeration Date:
01/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LAWRENCE
Authorized Official First Name:
CHARLOTTE
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
615-920-7000

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 540C110440 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1235315979 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 540C110440 . This is a "BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com