Healthcare Provider Details

I. General information

NPI: 1083771364
Provider Name (Legal Business Name): MCLAREN NORTHERN MICHIGAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 12/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 CONNABLE AVE
PETOSKEY MI
49770-2212
US

IV. Provider business mailing address

416 CONNABLE AVE
PETOSKEY MI
49770-2212
US

V. Phone/Fax

Practice location:
  • Phone: 231-487-4843
  • Fax: 231-487-4817
Mailing address:
  • Phone: 231-487-4843
  • Fax: 231-487-4817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number5301002202
License Number StateMI

VIII. Authorized Official

Name: MR. KEVIN PENDLETON
Title or Position: PHARMACY MANAGER
Credential: RPH
Phone: 231-487-4843