Provider Demographics
NPI:1275610263
Name:HOMETOWN PHARMACY INC
Entity Type:Organization
Organization Name:HOMETOWN PHARMACY INC
Other - Org Name:HOMETOWN PHARMACY #50 - NEW BUFFALO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE OPERATIONS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:REBEKAH
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:DESARMO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D, MBA
Authorized Official - Phone:231-652-7810
Mailing Address - Street 1:1 N WHITTAKER ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEW BUFFALO
Mailing Address - State:MI
Mailing Address - Zip Code:49117-1135
Mailing Address - Country:US
Mailing Address - Phone:269-469-3636
Mailing Address - Fax:269-469-3279
Practice Address - Street 1:1 N WHITTAKER ST
Practice Address - Street 2:
Practice Address - City:NEW BUFFALO
Practice Address - State:MI
Practice Address - Zip Code:49117-1135
Practice Address - Country:US
Practice Address - Phone:269-469-3636
Practice Address - Fax:269-469-3279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MI53010107883336C0003X
MI53010005443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2509352Medicaid
2156080OtherPK
MI2509352Medicaid