Provider Demographics
NPI:1346344306
Name:COUNTRY MARKET PHARMACIES LLC
Entity Type:Organization
Organization Name:COUNTRY MARKET PHARMACIES LLC
Other - Org Name:COUNTRY MARKET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:517-789-8980
Mailing Address - Street 1:1410 W GANSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-4063
Mailing Address - Country:US
Mailing Address - Phone:517-789-5149
Mailing Address - Fax:517-789-0115
Practice Address - Street 1:11301 BROOKLYN RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:MI
Practice Address - Zip Code:49230-8485
Practice Address - Country:US
Practice Address - Phone:517-592-2475
Practice Address - Fax:517-592-2558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MI53010079043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2046767OtherPK
MI1346344306Medicaid
0P48120Medicare PIN
2046767OtherPK
P00433595Medicare PIN