=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902914377
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PONTIAC TRAIL PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2006
-----------------------------------------------------
Last Update Date | 08/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 620 N. PONTIAC TRAIL
-----------------------------------------------------
City | WALLED LAKE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-669-2776
-----------------------------------------------------
Fax | 248-669-2835
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 43155 W. NINE MILE RD.
-----------------------------------------------------
City | NOVI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48376-8026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/R.PH.
-----------------------------------------------------
Name | MR. CARL ROBERT HENDRICKS
-----------------------------------------------------
Credential | R.PH
-----------------------------------------------------
Telephone | 248-669-2776
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 5301004197
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------