Provider Demographics
NPI:1356456388
Name:LIZNWES LLC
Entity Type:Organization
Organization Name:LIZNWES LLC
Other - Org Name:MEDICAP PHARMACY PETOSKEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:OSTRANDER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, MBA
Authorized Official - Phone:231-487-0262
Mailing Address - Street 1:2240 E. MITCHELL
Mailing Address - Street 2:STE A
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770
Mailing Address - Country:US
Mailing Address - Phone:231-487-0262
Mailing Address - Fax:231-487-0133
Practice Address - Street 1:2240 E. MITCHELL
Practice Address - Street 2:STE A
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770
Practice Address - Country:US
Practice Address - Phone:231-487-0262
Practice Address - Fax:231-487-0133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301008102333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2366789OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MI4931630Medicaid
2366789OtherOTHER ID NUMBER-COMMERCIAL NUMBER