Provider Demographics
NPI:1275648206
Name:HARBOR TOWN PHARMACY INC
Entity Type:Organization
Organization Name:HARBOR TOWN PHARMACY INC
Other - Org Name:HARBOR TOWN PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BROGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-884-2555
Mailing Address - Street 1:850 GREENLAND RD
Mailing Address - Street 2:
Mailing Address - City:ONTONAGON
Mailing Address - State:MI
Mailing Address - Zip Code:49953-1452
Mailing Address - Country:US
Mailing Address - Phone:906-884-4229
Mailing Address - Fax:906-884-6516
Practice Address - Street 1:850 GREENLAND RD
Practice Address - Street 2:
Practice Address - City:ONTONAGON
Practice Address - State:MI
Practice Address - Zip Code:49953-1452
Practice Address - Country:US
Practice Address - Phone:906-884-4229
Practice Address - Fax:906-884-6516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010052393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2042856OtherPK
MI2646404Medicaid