Healthcare Provider Details

I. General information

NPI: 1144421322
Provider Name (Legal Business Name): NORTHERN COUNTIES HLTH CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82 MAPLE STREET
ISLAND POND VT
05846-0425
US

IV. Provider business mailing address

PO BOX 425
ISLAND POND VT
05846-0425
US

V. Phone/Fax

Practice location:
  • Phone: 802-723-4300
  • Fax: 802-723-4544
Mailing address:
  • Phone: 802-723-4300
  • Fax: 802-723-4544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL COSTA
Title or Position: CEO
Credential:
Phone: 802-748-9405