Provider Demographics
NPI:1083771364
Name:MCLAREN NORTHERN MICHIGAN
Entity Type:Organization
Organization Name:MCLAREN NORTHERN MICHIGAN
Other - Org Name:NORTHERN MICHIGAN REGIONAL HOSPITAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PENDLETON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:231-487-4843
Mailing Address - Street 1:416 CONNABLE AVE
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2212
Mailing Address - Country:US
Mailing Address - Phone:231-487-4843
Mailing Address - Fax:231-487-4817
Practice Address - Street 1:416 CONNABLE AVE
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2212
Practice Address - Country:US
Practice Address - Phone:231-487-4843
Practice Address - Fax:231-487-4817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010022023336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2324349OtherNCPDP NUMBER
MI5171539Medicaid