Provider Demographics
NPI:1437164050
Name:FREEDOM APOTHECARY III INC
Entity Type:Organization
Organization Name:FREEDOM APOTHECARY III INC
Other - Org Name:NEW BOSTON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP AND PHARM
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:TJOLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:735-753-9480
Mailing Address - Street 1:PO BOX 691
Mailing Address - Street 2:
Mailing Address - City:NEW BOSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48164-0691
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19162 HURON RIVER DR
Practice Address - Street 2:
Practice Address - City:NEW BOSTON
Practice Address - State:MI
Practice Address - Zip Code:48164-9727
Practice Address - Country:US
Practice Address - Phone:734-753-9480
Practice Address - Fax:734-753-5397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301008319333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2368062OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MI5632880001Medicare NSC