Healthcare Provider Details

I. General information

NPI: 1992735666
Provider Name (Legal Business Name): PORTAGE PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7966 LOVERS LN
PORTAGE MI
49002-4446
US

IV. Provider business mailing address

7966 LOVERS LN
PORTAGE MI
49002-4446
US

V. Phone/Fax

Practice location:
  • Phone: 269-327-0033
  • Fax: 269-327-2709
Mailing address:
  • Phone: 269-327-0033
  • Fax: 269-327-2709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number5301002930
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberNP000798
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1994-43
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberNRP.022791200-03
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number035724
License Number StateNY
# 6
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054.017842
License Number StateIL
# 7
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number64002337A
License Number StateIN

VIII. Authorized Official

Name: LAWRENCE CURTIS
Title or Position: VICE PRESIDENT
Credential: R.PH.
Phone: 269-327-0033