Provider Demographics
NPI:1407925282
Name:COUNTRYSIDE DRUG COMPANY II
Entity Type:Organization
Organization Name:COUNTRYSIDE DRUG COMPANY II
Other - Org Name:COUNTRYSIDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:STRATTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-352-8168
Mailing Address - Street 1:9695 N GREENVILLE RD
Mailing Address - Street 2:PO BOX 527
Mailing Address - City:LAKEVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48850-9107
Mailing Address - Country:US
Mailing Address - Phone:989-352-8168
Mailing Address - Fax:989-352-6253
Practice Address - Street 1:9695 N GREENVILLE RD
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:MI
Practice Address - Zip Code:48850-9107
Practice Address - Country:US
Practice Address - Phone:989-352-8168
Practice Address - Fax:989-352-6253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010044233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1756241Medicaid
2039499OtherPK