MEDICARE: HACKLEY PROFESSIONAL PHARMACY, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336S0011X	Specialty Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013626639
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HACKLEY PROFESSIONAL PHARMACY, INC

Provider Business Mailing Address
First Line	:	1675 LEAHY ST STE 111
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49442-5538
Country	:	US
Telephone Number	:	231-672-7822
Fax Number	:	231-672-8425

Provider Business Practice Location Address
First Line	:	1675 LEAHY ST STE 111
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49442-5538
Country	:	US
Telephone Number	:	231-672-7822
Fax Number	:	231-672-8425

Authorized Official
Title or Position	:	PHARMACY MANAGER
Name	:	TARA ZDYBEL
Credential	:	PHARMD
Telephone Number	:	231-672-4899

Provider Enumeration Date	:	11/22/2022
Last Update Date	:	11/22/2022

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