Healthcare Provider Details

I. General information

NPI: 1437164050
Provider Name (Legal Business Name): FREEDOM APOTHECARY III INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 04/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19162 HURON RIVER DR
NEW BOSTON MI
48164-9727
US

IV. Provider business mailing address

PO BOX 691
NEW BOSTON MI
48164-0691
US

V. Phone/Fax

Practice location:
  • Phone: 734-753-9480
  • Fax: 734-753-5397
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number5301008319
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MARTHA TJOLSEN
Title or Position: VP AND PHARM
Credential: RPH
Phone: 735-753-9480