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General NPI Number Information
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NPI Number | 1265445936
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Entity Type | Organization
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Legal Business Name | COUNTRY SQUIRE DISCOUNT PHARMACY, INC
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Dates
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Enumeration Date | 08/14/2006
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Last Update Date | 07/28/2014
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Provider Practice Location Address
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Address Line | 30 E MAIN ST
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City | FREMONT
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State | MI
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Zip | 49412-1244
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Country | US
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Telephone | 231-924-2120
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Fax | 231-924-6310
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Provider Business Mailing Address
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Address Line | 30 E MAIN ST
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City | FREMONT
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State | MI
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Zip | 49412-1244
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Country | US
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Telephone | 231-924-2120
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Fax | 231-924-6310
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Authorized Official
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Title or Position | PRESIDENT
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Name | JUDSON AFMAN
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Credential |
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Telephone | 231-924-2120
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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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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Taxonomy #3
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 5301001172
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License Number State | MI
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