MEDICARE: MED CARE PHARMACY SERVICES LLC

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	3336C0003X	Community/Retail Pharmacy	5315068331	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2147044	OTHER		PK

General Provider Information

NPI Number	:	1073911996
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MED CARE PHARMACY SERVICES LLC

Provider Business Mailing Address
First Line	:	360 E CHICAGO ST
Second Line	:	SUITE 105
City	:	COLDWATER
State	:	MI
Zip	:	49036-2074
Country	:	US
Telephone Number	:	517-924-1400
Fax Number	:	517-924-1401

Provider Business Practice Location Address
First Line	:	360 E CHICAGO ST
Second Line	:	SUITE 105
City	:	COLDWATER
State	:	MI
Zip	:	49036-2074
Country	:	US
Telephone Number	:	517-924-1400
Fax Number	:	517-924-1401

Authorized Official
Title or Position	:	CEO
Name	:	MANJUNATH BAGEWADI ELLUR
Credential	:
Telephone Number	:	646-897-7522

Provider Enumeration Date	:	12/09/2014
Last Update Date	:	12/25/2014

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