Provider Demographics
NPI:1235556101
Name:ASPIRUS KEWEENAW ENTERPRISES INC
Entity Type:Organization
Organization Name:ASPIRUS KEWEENAW ENTERPRISES INC
Other - Org Name:ASPIRUS HOUGHTON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGISTERED PHARMACIST/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:PENEGOR
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:906-231-8009
Mailing Address - Street 1:1000 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:49931-1978
Mailing Address - Country:US
Mailing Address - Phone:906-231-8009
Mailing Address - Fax:906-231-8030
Practice Address - Street 1:1000 CEDAR ST
Practice Address - Street 2:
Practice Address - City:HOUGHTON
Practice Address - State:MI
Practice Address - Zip Code:49931-1978
Practice Address - Country:US
Practice Address - Phone:906-231-8009
Practice Address - Fax:906-231-8030
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASPIRUS KEWEENAW HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-03-27
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2858024Medicaid