MEDICARE: FREEDOM APOTHECARY III 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	333600000X	Pharmacy	5301008319	MI
2	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2368062	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1437164050
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FREEDOM APOTHECARY III INC

Provider Business Mailing Address
First Line	:	PO BOX 691
Second Line	:
City	:	NEW BOSTON
State	:	MI
Zip	:	48164-0691
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	19162 HURON RIVER DR
Second Line	:
City	:	NEW BOSTON
State	:	MI
Zip	:	48164-9727
Country	:	US
Telephone Number	:	734-753-9480
Fax Number	:	734-753-5397

Authorized Official
Title or Position	:	VP AND PHARM
Name	:	MARTHA TJOLSEN
Credential	:	RPH
Telephone Number	:	735-753-9480

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	04/09/2008

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