Provider Demographics
NPI:1265445936
Name:COUNTRY SQUIRE DISCOUNT PHARMACY, INC
Entity Type:Organization
Organization Name:COUNTRY SQUIRE DISCOUNT PHARMACY, INC
Other - Org Name:COUNTRY SQUIRE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUDSON
Authorized Official - Middle Name:
Authorized Official - Last Name:AFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-924-2120
Mailing Address - Street 1:30 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49412-1244
Mailing Address - Country:US
Mailing Address - Phone:231-924-2120
Mailing Address - Fax:231-924-6310
Practice Address - Street 1:30 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-1244
Practice Address - Country:US
Practice Address - Phone:231-924-2120
Practice Address - Fax:231-924-6310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MI53010011723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1878530Medicaid
2039663OtherPK
MI1878530Medicaid