Healthcare Provider Details

I. General information

NPI: 1619272457
Provider Name (Legal Business Name): EAGLE PHARMACY OF FARWELL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2011
Last Update Date: 06/25/2023
Certification Date: 06/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 W MAIN ST
FARWELL MI
48622-9553
US

IV. Provider business mailing address

11271 HARRISON AVE
FARWELL MI
48622-9439
US

V. Phone/Fax

Practice location:
  • Phone: 989-588-2900
  • Fax: 989-588-2901
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 Number5301009495
License Number StateMI

VIII. Authorized Official

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