=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467740688
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIKES FAMILY PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2011
-----------------------------------------------------
Last Update Date | 10/25/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8718 WATER ST STE A
-----------------------------------------------------
City | MONTAGUE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49437-1204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-894-8633
-----------------------------------------------------
Fax | 231-893-3530
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8718 WATER ST SUITE A
-----------------------------------------------------
City | MONTAGUE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49437-1204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-894-8633
-----------------------------------------------------
Fax | 231-893-3530
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHAEL COOK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 231-740-6025
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 5301009749
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------