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General NPI Number Information
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NPI Number | 1407925282
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Entity Type | Organization
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Legal Business Name | COUNTRYSIDE DRUG COMPANY II
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Dates
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Enumeration Date | 11/07/2006
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Last Update Date | 10/16/2017
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Provider Practice Location Address
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Address Line | 9695 N GREENVILLE RD
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City | LAKEVIEW
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State | MI
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Zip | 48850-9107
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Country | US
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Telephone | 989-352-8168
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Fax | 989-352-6253
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Provider Business Mailing Address
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Address Line | 9695 N GREENVILLE RD PO BOX 527
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City | LAKEVIEW
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State | MI
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Zip | 48850-9107
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Country | US
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Telephone | 989-352-8168
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Fax | 989-352-6253
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Authorized Official
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Title or Position | CFO
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Name | SUSAN L STRATTON
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Credential |
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Telephone | 989-352-8168
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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 | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 5301004423
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License Number State | MI
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