=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639243157
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PENNOCK PHARMACY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2006
-----------------------------------------------------
Last Update Date | 04/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1005 W GREEN ST
-----------------------------------------------------
City | HASTINGS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49058-1712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-948-3136
-----------------------------------------------------
Fax | 269-948-3134
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1005 W GREEN ST
-----------------------------------------------------
City | HASTINGS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49058-1712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-948-3136
-----------------------------------------------------
Fax | 269-948-3134
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CERTIFIED PHARMACY TECHNICIAN
-----------------------------------------------------
Name | AMANDA RISNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 269-945-1212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 5301004710
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------