Healthcare Provider Details

I. General information

NPI: 1487793436
Provider Name (Legal Business Name): HACKLEY PHARMACY NORTON SHORES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 02/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 PARK ST STE 104
MUSKEGON MI
49444-3736
US

IV. Provider business mailing address

3535 PARK ST STE 104
MUSKEGON MI
49444-3736
US

V. Phone/Fax

Practice location:
  • Phone: 231-739-9302
  • Fax: 231-728-1604
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301008544
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number
License Number State

VIII. Authorized Official

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