Healthcare Provider Details

I. General information

NPI: 1568091957
Provider Name (Legal Business Name): BLUE WATER PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2020
Last Update Date: 08/25/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 10TH STREET
PORT HURON MI
48060
US

IV. Provider business mailing address

1524 10TH STREET
PORT HURON MI
48060
US

V. Phone/Fax

Practice location:
  • Phone: 810-982-3100
  • Fax: 810-982-3106
Mailing address:
  • Phone: 813-304-2221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ALPESH PATEL
Title or Position: OWNER
Credential:
Phone: 813-304-2221