{
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
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"NamePrefix": null,
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"FirstLineMailingAddress": "4180 W VIENNA RD STE 4",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "CLIO",
"MailingAddressStateName": "MI",
"MailingAddressPostalCode": "48420-9497",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "810-547-7201",
"MailingAddressFaxNumber": "810-309-9075",
"FirstLinePracticeLocationAddress": "4180 W VIENNA RD STE 4",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "CLIO",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "810-547-7201",
"PracticeLocationAddressFaxNumber": "810-309-9075",
"EnumerationDate": "05/01/2024",
"LastUpdateDate": "05/01/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "FOSKETT",
"AuthorizedOfficialFirstName": "RONALD",
"AuthorizedOfficialMiddleName": "TODD",
"AuthorizedOfficialTitle": "PHARMACIST IN CHARGE",
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"AuthorizedOfficialTelephoneNumber": "810-547-7201",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "3336L0003X",
"TaxonomyName": "Long Term Care Pharmacy",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}