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General NPI Number Information
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NPI Number | 1053133975
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Entity Type | Organization
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Legal Business Name | BEAVERTON FAMILY PHARMACY LLC
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Dates
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Enumeration Date | 10/30/2024
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Last Update Date | 10/30/2024
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Provider Practice Location Address
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Address Line | 3210 W LANG RD
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City | BEAVERTON
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State | MI
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Zip | 48612-8102
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Country | US
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Telephone | 989-339-9008
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Fax |
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Provider Business Mailing Address
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Address Line | 11271 HARRISON AVE
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City | FARWELL
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State | MI
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Zip | 48622-9439
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JOHN GROSS
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Credential |
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Telephone | 989-339-9008
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number |
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License Number State |
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