Healthcare Provider Details

I. General information

NPI: 1700887148
Provider Name (Legal Business Name): THE COUNTRY SQUIRE DISCOUNT PHARMACY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 07/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 E MAIN
FREMONT MI
49412-1244
US

IV. Provider business mailing address

30 E MAIN
FREMONT MI
49412-1244
US

V. Phone/Fax

Practice location:
  • Phone: 231-924-2120
  • Fax: 231-924-6310
Mailing address:
  • Phone: 231-924-2120
  • Fax: 231-924-6310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number5301001172
License Number StateMI

VIII. Authorized Official

Name: MR. JUDSON K AFMAN
Title or Position: PRESIDENT
Credential: R. PH.
Phone: 231-924-2120