Provider Demographics
NPI:1538405774
Name:LTC PHARMACY, LLC
Entity type:Organization
Organization Name:LTC PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHOEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-214-8011
Mailing Address - Street 1:4477 E PARIS AVE SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49512-5312
Mailing Address - Country:US
Mailing Address - Phone:616-214-8011
Mailing Address - Fax:616-554-9581
Practice Address - Street 1:4477 E PARIS AVE SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49512-5312
Practice Address - Country:US
Practice Address - Phone:616-214-8011
Practice Address - Fax:616-554-9581
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRESCRIPTION SUPPLY INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-17
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301009544333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1588963706Medicaid
MI1588963706Medicaid