Healthcare Provider Details

I. General information

NPI: 1902968084
Provider Name (Legal Business Name): LAKELAND PHARMACY BERRIEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6418 DEANS HILL RD
BERRIEN CENTER MI
49102-9750
US

IV. Provider business mailing address

6418 DEANS HILL RD
BERRIEN CENTER MI
49102-9750
US

V. Phone/Fax

Practice location:
  • Phone: 269-473-3082
  • Fax:
Mailing address:
  • Phone: 269-473-3082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number5301006978
License Number StateMI

VIII. Authorized Official

Name: NEIL R JOHNSON
Title or Position: MANAGER
Credential: R.PH.
Phone: 269-473-3082