Healthcare Provider Details

I. General information

NPI: 1902914377
Provider Name (Legal Business Name): PONTIAC TRAIL PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2006
Last Update Date: 08/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N. PONTIAC TRAIL
WALLED LAKE MI
48390
US

IV. Provider business mailing address

43155 W. NINE MILE RD.
NOVI MI
48376-8026
US

V. Phone/Fax

Practice location:
  • Phone: 248-669-2776
  • Fax: 248-669-2835
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301004197
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. CARL ROBERT HENDRICKS
Title or Position: OWNER/R.PH.
Credential: R.PH
Phone: 248-669-2776