Provider Demographics
NPI:1225188485
Name:FOSTER'S SUPER MARKETS, INC
Entity Type:Organization
Organization Name:FOSTER'S SUPER MARKETS, INC
Other - Org Name:JERRY'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VINH
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-839-5800
Mailing Address - Street 1:PO BOX 430
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49651-0430
Mailing Address - Country:US
Mailing Address - Phone:231-839-5800
Mailing Address - Fax:231-839-2206
Practice Address - Street 1:5760 WEST HOUGHTON LAKE ROAD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MI
Practice Address - Zip Code:49651-0430
Practice Address - Country:US
Practice Address - Phone:231-839-5800
Practice Address - Fax:231-839-2206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3245615Medicaid
MI3245615Medicaid