=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366440612
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BALLENTINE PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3482 MAIN ST
-----------------------------------------------------
City | DECKERVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48427-9633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-376-2825
-----------------------------------------------------
Fax | 810-376-8355
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3482 MAIN ST PO BOX 67
-----------------------------------------------------
City | DECKERVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48427-9633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOAN BALLENTINE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 810-376-2825
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 5301000086
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------