Provider Demographics
NPI:1417055567
Name:MISSION PHARMACY, LLC
Entity Type:Organization
Organization Name:MISSION PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:LUNDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:989-773-8200
Mailing Address - Street 1:926 S MISSION
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858
Mailing Address - Country:US
Mailing Address - Phone:989-773-8200
Mailing Address - Fax:989-773-8282
Practice Address - Street 1:926 S MISSION
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858
Practice Address - Country:US
Practice Address - Phone:989-773-8200
Practice Address - Fax:989-773-8282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010065733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3354754Medicaid
2356980OtherNCPDP
BM5316674OtherDEA
MI3354754Medicaid