MEDICARE: BALD MOUNTAIN MEDICAL PHARMACY

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	5301007701	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2364862	OTHER	MI	NCPDP

General Provider Information

NPI Number	:	1588770606
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALD MOUNTAIN MEDICAL PHARMACY

Provider Business Mailing Address
First Line	:	1375 S LAPEER RD STE 103
Second Line	:
City	:	LAKE ORION
State	:	MI
Zip	:	48360-1421
Country	:	US
Telephone Number	:	248-814-9814
Fax Number	:	248-814-9818

Provider Business Practice Location Address
First Line	:	1375 S LAPEER RD STE 103
Second Line	:
City	:	LAKE ORION
State	:	MI
Zip	:	48360-1421
Country	:	US
Telephone Number	:	248-814-9814
Fax Number	:	248-814-9818

Authorized Official
Title or Position	:	OWNER
Name	:	MR. PIERRE BOUTRAS
Credential	:	RPH
Telephone Number	:	248-814-9814

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	08/22/2020

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Practice Location Address:

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Practice Location Address:

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Directions to “BALD MOUNTAIN MEDICAL PHARMACY ” Practice Location

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