Healthcare Provider Details

I. General information

NPI: 1124169081
Provider Name (Legal Business Name): HACKLEY PHARMACY MUSKEGON HTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 09/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 BAKER ST ROBERT A WARREN BLDG
MUSKEGON HEIGHTS MI
49444-2157
US

IV. Provider business mailing address

2700 BAKER ST ROBERT A WARREN BLDG
MUSKEGON HEIGHTS MI
49444-2157
US

V. Phone/Fax

Practice location:
  • Phone: 231-737-9510
  • Fax: 231-739-0837
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number5301006384
License Number StateMI

VIII. Authorized Official

Name: CARTER BOSSE
Title or Position: DIRECTOR OF PHARMACY
Credential:
Phone: 231-728-5974