Healthcare Provider Details

I. General information

NPI: 1275610263
Provider Name (Legal Business Name): HOMETOWN PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 04/10/2020
Certification Date: 04/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 N WHITTAKER ST
NEW BUFFALO MI
49117-1135
US

IV. Provider business mailing address

1 N WHITTAKER ST SUITE A
NEW BUFFALO MI
49117-1135
US

V. Phone/Fax

Practice location:
  • Phone: 269-469-3636
  • Fax: 269-469-3279
Mailing address:
  • Phone: 269-469-3636
  • Fax: 269-469-3279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301010788
License Number StateMI

VIII. Authorized Official

Name: REBEKAH LYN DESARMO
Title or Position: EXECUTIVE OPERATIONS ADMINISTRATOR
Credential: PHARM D., MBA
Phone: 231-652-7810