Provider Demographics
NPI:1902914377
Name:PONTIAC TRAIL PHARMACY INC
Entity Type:Organization
Organization Name:PONTIAC TRAIL PHARMACY INC
Other - Org Name:PONTIAC TRAIL MEDICAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/R.PH.
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:248-669-2776
Mailing Address - Street 1:43155 W. NINE MILE RD.
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48376-8026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:620 N. PONTIAC TRAIL
Practice Address - Street 2:
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390
Practice Address - Country:US
Practice Address - Phone:248-669-2776
Practice Address - Fax:248-669-2835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-27
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QH0100X, 332B00000X, 3336L0003X
MI53010041973336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2338689Medicaid
MI1665835Medicaid
MI1649484Medicaid
2338689OtherOTHER ID NUMBER
MI1649484Medicaid