Provider Demographics
NPI:1215190376
Name:BENGRY PHARMACY PC
Entity Type:Organization
Organization Name:BENGRY PHARMACY PC
Other - Org Name:HOLIHANS DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BENGRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-734-2551
Mailing Address - Street 1:PO BOX 515
Mailing Address - Street 2:
Mailing Address - City:EVART
Mailing Address - State:MI
Mailing Address - Zip Code:49631-0515
Mailing Address - Country:US
Mailing Address - Phone:231-734-2551
Mailing Address - Fax:231-734-5890
Practice Address - Street 1:128 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EVART
Practice Address - State:MI
Practice Address - Zip Code:49631-9416
Practice Address - Country:US
Practice Address - Phone:231-734-2551
Practice Address - Fax:231-734-5890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-08
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010040053336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2118394OtherPK
MI1592882Medicaid
MI1967001Medicaid
0179570001Medicare NSC