Provider Demographics
NPI:1417064650
Name:PIONEER FAMILY PHARMACY INC
Entity Type:Organization
Organization Name:PIONEER FAMILY PHARMACY INC
Other - Org Name:PIONEER FAMILY PHARMACY #104
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAIDWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:989-389-7277
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:
Mailing Address - City:ROSCOMMON
Mailing Address - State:MI
Mailing Address - Zip Code:48653-0547
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:412 N 5TH ST
Practice Address - Street 2:
Practice Address - City:ROSCOMMON
Practice Address - State:MI
Practice Address - Zip Code:48653-9329
Practice Address - Country:US
Practice Address - Phone:989-275-5600
Practice Address - Fax:989-275-4707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010084433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2368668Medicaid
2042339OtherPK
2042339OtherPK