Healthcare Provider Details

I. General information

NPI: 1194555201
Provider Name (Legal Business Name): BEAVERTON FAMILY PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2024
Last Update Date: 08/05/2024
Certification Date: 08/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 W LANG RD
BEAVERTON MI
48612-8102
US

IV. Provider business mailing address

11271 HARRISON AVE
FARWELL MI
48622-9439
US

V. Phone/Fax

Practice location:
  • Phone: 989-339-9008
  • Fax: 855-855-4919
Mailing address:
  • Phone: 989-339-9008
  • Fax: 855-855-4919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JOHN GROSS
Title or Position: OWNER
Credential: RPH
Phone: 989-339-9008