Provider Demographics
NPI:1003905589
Name:FREEDOM APOTHECARY INC
Entity Type:Organization
Organization Name:FREEDOM APOTHECARY INC
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:TJOLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:734-429-0509
Mailing Address - Street 1:PO BOX 663
Mailing Address - Street 2:75 E BENNETT
Mailing Address - City:SALINE
Mailing Address - State:MI
Mailing Address - Zip Code:48176-0663
Mailing Address - Country:US
Mailing Address - Phone:734-429-0509
Mailing Address - Fax:
Practice Address - Street 1:75 E BENNETT ST
Practice Address - Street 2:
Practice Address - City:SALINE
Practice Address - State:MI
Practice Address - Zip Code:48176-1204
Practice Address - Country:US
Practice Address - Phone:734-429-0509
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010073763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2341054OtherNCPDP NUMBER
MI1773930Medicaid
MI1773930Medicaid
MI1773930Medicaid