Provider Demographics
NPI:1285645796
Name:DECATUR PHARMACY
Entity Type:Organization
Organization Name:DECATUR PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUEGER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:269-423-2821
Mailing Address - Street 1:100 W SHERWOOD ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:MI
Mailing Address - Zip Code:49045-1120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 W SHERWOOD ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:MI
Practice Address - Zip Code:49045-1120
Practice Address - Country:US
Practice Address - Phone:269-423-2821
Practice Address - Fax:269-423-7443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
MI5301007414333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2313524Medicaid
2313524OtherOTHER ID NUMBER-COMMERCIAL NUMBER
2313524OtherOTHER ID NUMBER-COMMERCIAL NUMBER