Provider Demographics
NPI:1528158441
Name:THUNDER BAY COMMUNITY HEALTH SERVICE, INC
Entity type:Organization
Organization Name:THUNDER BAY COMMUNITY HEALTH SERVICE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:WINEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-785-5535
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:11899 M32
Mailing Address - City:ATLANTA
Mailing Address - State:MI
Mailing Address - Zip Code:49709-0850
Mailing Address - Country:US
Mailing Address - Phone:989-785-5535
Mailing Address - Fax:989-785-5267
Practice Address - Street 1:11899 M 32
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:MI
Practice Address - Zip Code:49709-9374
Practice Address - Country:US
Practice Address - Phone:989-785-5535
Practice Address - Fax:989-785-5267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X
MI53010075633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2363959Medicaid
2363959OtherNCPDP PROVIDER IDENTIFICATION NUMBER