Provider Demographics
NPI:1144304890
Name:HOMETOWN PHARMACY INC
Entity type:Organization
Organization Name:HOMETOWN PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE OPERATIONS ADMINSTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:REBEKAH
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:DESARMO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D, MBA
Authorized Official - Phone:231-652-7810
Mailing Address - Street 1:60 E 82ND STREET
Mailing Address - Street 2:PO BOX 884
Mailing Address - City:NEWAYGO
Mailing Address - State:MI
Mailing Address - Zip Code:49337
Mailing Address - Country:US
Mailing Address - Phone:231-652-7810
Mailing Address - Fax:231-652-7876
Practice Address - Street 1:730 WEST SHAW
Practice Address - Street 2:
Practice Address - City:HOWARD CITY
Practice Address - State:MI
Practice Address - Zip Code:49329
Practice Address - Country:US
Practice Address - Phone:231-937-5282
Practice Address - Fax:231-937-7472
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOME TOWN PHARMACY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-25
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010057783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5301005778OtherBOARD OF PHARMACY
2350534OtherNCPDP NUMBER