Healthcare Provider Details

I. General information

NPI: 1720920341
Provider Name (Legal Business Name): INDIAN RIVER PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3944 S STRAITS HWY
INDIAN RIVER MI
49749-5135
US

IV. Provider business mailing address

3944 S STRAITS HWY
INDIAN RIVER MI
49749-5135
US

V. Phone/Fax

Practice location:
  • Phone: 231-238-2499
  • Fax: 231-238-2496
Mailing address:
  • Phone: 231-238-2499
  • Fax: 231-238-2496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: JAMES MAURITZ GLOMBOWSKI
Title or Position: OWNER/PHARMACIST
Credential: RPH
Phone: 989-330-7840