| NPI |
1275648206 |
The 10-position telephone number of the authorized official. |
| Entity Type Code |
2 |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Employer Identification Number EIN |
|
|
| Provider Organization Name Legal Business Name |
HARBOR TOWN PHARMACY INC |
|
| Provider Other Organization Name |
HARBOR TOWN PHARMACY INC |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
| Provider Other Organization Name Type Code |
3 |
|
| Provider First Line Business Practice Location Address |
850 GREENLAND RD |
|
| Provider Business Practice Location Address City Name |
ONTONAGON |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
| Provider Business Practice Location Address State Name |
MI |
|
| Provider Business Practice Location Address Postal Code |
499531452 |
|
| Provider Business Practice Location Address Country Code If outside U S |
US |
|
| Provider Business Practice Location Address Telephone Number |
9068844229 |
|
| Provider Business Practice Location Address Fax Number |
9068846516 |
|
| Provider Enumeration Date |
8/20/2006 |
|
| Last Update Date |
1/17/2017 |
|
| Authorized Official Last Name |
BROGAN |
|
| Authorized Official First Name |
JAMES |
The first name of the authorized official. |
| Authorized Official Title or Position |
OWNER/PRESIDENT |
The title or position of the authorized official. |
| Authorized Official Telephone Number |
9068842555 |
The 10-position telephone number of the authorized official. |
| Healthcare Provider Taxonomy Code 1 |
333600000X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Healthcare Provider Primary Taxonomy Switch 1 |
N |
|
| Healthcare Provider Taxonomy Code 2 |
3336C0003X |
|
| Provider License Number 2 |
5301005239 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
| Provider License Number State Code 2 |
MI |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
| Healthcare Provider Primary Taxonomy Switch 2 |
Y |
|
| Other Provider Identifier 1 |
2646404 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 1 |
05 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 1 |
MI |
|
| Other Provider Identifier 2 |
2042856 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 2 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Issuer 2 |
PK |
|
| Is Organization Subpart |
N |
|