Healthcare Provider Details

I. General information

NPI: 1538484209
Provider Name (Legal Business Name): NORTHSHORE PORTAGE STERLING CREEK PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2010
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6050 STERLING CREEK RD
PORTAGE IN
46368-7752
US

IV. Provider business mailing address

PO BOX 1430
PORTAGE IN
46368-9230
US

V. Phone/Fax

Practice location:
  • Phone: 219-763-8112
  • Fax: 219-764-5380
Mailing address:
  • Phone: 219-763-8112
  • Fax: 219-764-5380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DAVID HALL
Title or Position: CEO
Credential:
Phone: 219-763-8112