Provider Demographics
NPI:1093229361
Name:HORIZON PHARMACY LTC, LLC
Entity Type:Organization
Organization Name:HORIZON PHARMACY LTC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-591-9595
Mailing Address - Street 1:PO BOX 87
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49083-0087
Mailing Address - Country:US
Mailing Address - Phone:616-913-2007
Mailing Address - Fax:616-913-3060
Practice Address - Street 1:4150 KALAMAZOO AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-3605
Practice Address - Country:US
Practice Address - Phone:616-591-9595
Practice Address - Fax:616-208-9596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-25
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1093229361Medicaid
2174038OtherPK