MEDICARE: HOMETOWN 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
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	333600000X	Pharmacy
4	3336L0003X	Long Term Care Pharmacy
5	3336C0003X	Community/Retail Pharmacy	5301010897	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2158175	OTHER		PK

General Provider Information

NPI Number	:	1578670410
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOMETOWN PHARMACY INC

Provider Business Mailing Address
First Line	:	4252 KALAMAZOO AVE SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-3607
Country	:	US
Telephone Number	:	616-281-1323
Fax Number	:	616-281-1330

Provider Business Practice Location Address
First Line	:	4252 KALAMAZOO AVE SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-3607
Country	:	US
Telephone Number	:	616-281-1323
Fax Number	:	616-281-1330

Authorized Official
Title or Position	:	EXECUTIVE OPERATIONS ADMINISTRATOR
Name	:	REBEKAH LYN DESARMO
Credential	:
Telephone Number	:	231-652-7810

Provider Enumeration Date	:	08/24/2006
Last Update Date	:	04/14/2020

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Directions to “HOMETOWN PHARMACY INC ” Practice Location

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