Healthcare Provider Details

I. General information

NPI: 1265445936
Provider Name (Legal Business Name): COUNTRY SQUIRE DISCOUNT PHARMACY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 07/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 E MAIN ST
FREMONT MI
49412-1244
US

IV. Provider business mailing address

30 E MAIN ST
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 TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301001172
License Number StateMI

VIII. Authorized Official

Name: JUDSON AFMAN
Title or Position: PRESIDENT
Credential:
Phone: 231-924-2120