Provider Demographics
NPI:1043310220
Name:MYMICHIGAN MEDICAL CENTER ALPENA
Entity Type:Organization
Organization Name:MYMICHIGAN MEDICAL CENTER ALPENA
Other - Org Name:MIDMICHIGAN MEDICAL CENTER - ALPENA OUTPATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAPLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:989-356-7375
Mailing Address - Street 1:4000 WELLNESS DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48670-0001
Mailing Address - Country:US
Mailing Address - Phone:989-356-7757
Mailing Address - Fax:989-356-8076
Practice Address - Street 1:1501 W CHISHOLM ST
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1401
Practice Address - Country:US
Practice Address - Phone:989-356-7757
Practice Address - Fax:989-356-8076
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MYMICHIGAN HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-25
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010109063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1043310220Medicaid
2040660OtherPK
MI2312128Medicaid