MEDICARE: HACKLEY PHARMACY MUSKEGON HTS

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	3336C0002X	Clinic Pharmacy
2	3336C0003X	Community/Retail Pharmacy
3	333600000X	Pharmacy	5301006384	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	2355510	OTHER	OTHER ID NUMBER-COMMERCIAL NUMBER
2	2355510	OTHER	OTHER ID NUMBER
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124169081
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HACKLEY PHARMACY MUSKEGON HTS

Provider Business Mailing Address
First Line	:	2700 BAKER ST
Second Line	:	ROBERT A WARREN BLDG
City	:	MUSKEGON HEIGHTS
State	:	MI
Zip	:	49444-2157
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2700 BAKER ST
Second Line	:	ROBERT A WARREN BLDG
City	:	MUSKEGON HEIGHTS
State	:	MI
Zip	:	49444-2157
Country	:	US
Telephone Number	:	231-737-9510
Fax Number	:	231-739-0837

Authorized Official
Title or Position	:	DIRECTOR OF PHARMACY
Name	:	CARTER BOSSE
Credential	:
Telephone Number	:	231-728-5974

Provider Enumeration Date	:	02/12/2007
Last Update Date	:	09/12/2007

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