Provider Demographics
NPI:1114972270
Name:PH COPPER COUNTRY APOTHECARIES LLC
Entity Type:Organization
Organization Name:PH COPPER COUNTRY APOTHECARIES LLC
Other - Org Name:APOTHECARY HOUGHTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:TERRANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:DILLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-596-7220
Mailing Address - Street 1:600 MACINNES DR
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:49931-1144
Mailing Address - Country:US
Mailing Address - Phone:906-483-1818
Mailing Address - Fax:906-483-1811
Practice Address - Street 1:600 MACINNES DR
Practice Address - Street 2:
Practice Address - City:HOUGHTON
Practice Address - State:MI
Practice Address - Zip Code:49931-1144
Practice Address - Country:US
Practice Address - Phone:906-483-1818
Practice Address - Fax:906-483-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010102473336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1114972270Medicaid
2143559OtherPK