MEDICARE: BRONSON VILLAGE DRUG, 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	3336L0003X	Long Term Care Pharmacy

General Provider Information

NPI Number	:	1639851116
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRONSON VILLAGE DRUG, INC.

Provider Business Mailing Address
First Line	:	25344 RED ARROW HWY
Second Line	:
City	:	MATTAWAN
State	:	MI
Zip	:	49071-9742
Country	:	US
Telephone Number	:	833-697-0008
Fax Number	:

Provider Business Practice Location Address
First Line	:	3622 VETERANS DR STE 1&2
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-4579
Country	:	US
Telephone Number	:	833-697-0008
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JEFFREY ROBERT STULL
Credential	:	PHARM.D.
Telephone Number	:	269-657-6073

Provider Enumeration Date	:	08/03/2023
Last Update Date	:	08/03/2023

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Directions to “BRONSON VILLAGE DRUG, INC. ” Practice Location

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