Provider Demographics
NPI:1285644997
Name:MESICK PHARMACY INC
Entity Type:Organization
Organization Name:MESICK PHARMACY INC
Other - Org Name:MESICK PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CONRAD
Authorized Official - Last Name:RUNYON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:231-775-5073
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:112 MESICK AVE
Mailing Address - City:MESICK
Mailing Address - State:MI
Mailing Address - Zip Code:49668
Mailing Address - Country:US
Mailing Address - Phone:231-885-1751
Mailing Address - Fax:231-885-1998
Practice Address - Street 1:112 MESICK AVE
Practice Address - Street 2:
Practice Address - City:MESICK
Practice Address - State:MI
Practice Address - Zip Code:49668
Practice Address - Country:US
Practice Address - Phone:231-885-1751
Practice Address - Fax:231-885-1998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301003492333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2328789Medicaid
MI0267270001Medicare NSC