=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902817414
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELMERS PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2006
-----------------------------------------------------
Last Update Date | 08/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 412 N LINCOLN RD
-----------------------------------------------------
City | ESCANABA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49829-1365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-789-9200
-----------------------------------------------------
Fax | 906-789-2118
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 412 N LINCOLN RD
-----------------------------------------------------
City | ESCANABA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49829-1365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-789-9200
-----------------------------------------------------
Fax | 906-789-2118
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MGR
-----------------------------------------------------
Name | MICHAEL ELENICH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 906-789-9200
-----------------------------------------------------
=====================================================
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 | 5301004386
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------