Provider Demographics
NPI:1093016438
Name:SUSANS TOTAL CARE DRUG STORE LLC
Entity Type:Organization
Organization Name:SUSANS TOTAL CARE DRUG STORE LLC
Other - Org Name:SUSAN'S TOTAL CARE DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RPH/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MEISNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-379-7000
Mailing Address - Street 1:22432 HURON RIVER DR
Mailing Address - Street 2:
Mailing Address - City:ROCKWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:48173-1100
Mailing Address - Country:US
Mailing Address - Phone:734-379-7000
Mailing Address - Fax:734-379-7037
Practice Address - Street 1:22432 HURON RIVER DR
Practice Address - Street 2:
Practice Address - City:ROCKWOOD
Practice Address - State:MI
Practice Address - Zip Code:48173-1100
Practice Address - Country:US
Practice Address - Phone:734-379-7000
Practice Address - Fax:734-379-7037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-16
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X, 3336S0011X
MI53010094543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1093016438Medicaid
2374673OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MI6581100001Medicare NSC