Healthcare Provider Details

I. General information

NPI: 1851459077
Provider Name (Legal Business Name): COUNTRYSIDE DRUG COMPANY III
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 04/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 E MAIN ST
EDMORE MI
48829-9709
US

IV. Provider business mailing address

PO BOX 197
EDMORE MI
48829-0197
US

V. Phone/Fax

Practice location:
  • Phone: 989-427-5141
  • Fax: 989-427-5142
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301005214
License Number StateMI

VIII. Authorized Official

Name: CARRIE DEAL
Title or Position: MANG
Credential: RPH
Phone: 989-427-5141