MEDICARE: PROFESSIONAL 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	3336C0003X	Community/Retail Pharmacy
2	3336C0003X	Community/Retail Pharmacy	5301004303	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992801625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL PHARMACY INC

Provider Business Mailing Address
First Line	:	9175 CHERRY VALLEY AVE SE
Second Line	:
City	:	CALEDONIA
State	:	MI
Zip	:	49316-9746
Country	:	US
Telephone Number	:	616-891-1116
Fax Number	:	616-891-0080

Provider Business Practice Location Address
First Line	:	9175 CHERRY VALLEY AVE SE
Second Line	:
City	:	CALEDONIA
State	:	MI
Zip	:	49316-9746
Country	:	US
Telephone Number	:	616-891-1116
Fax Number	:	616-891-0080

Authorized Official
Title or Position	:	OWNER
Name	:	KRISTIN RAREDON
Credential	:
Telephone Number	:	616-891-1116

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	03/02/2017

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Directions to “PROFESSIONAL PHARMACY INC ” Practice Location

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