Provider Demographics
NPI:1184670085
Name:HILL'S PHARMACY OF VICKSBURG, INC.
Entity Type:Organization
Organization Name:HILL'S PHARMACY OF VICKSBURG, INC.
Other - Org Name:HILL'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SOEKARMOEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:269-649-1476
Mailing Address - Street 1:110 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49097-1211
Mailing Address - Country:US
Mailing Address - Phone:269-649-1476
Mailing Address - Fax:269-649-4007
Practice Address - Street 1:110 S MAIN ST
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MI
Practice Address - Zip Code:49097-1211
Practice Address - Country:US
Practice Address - Phone:269-649-1476
Practice Address - Fax:269-649-4007
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HILL'S PHARMACY OF VICKSBURG, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-25
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010057363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540C912930OtherBCBS MICHIGAN
MI872508050Medicaid
MI4761810001Medicare ID - Type Unspecified