Provider Demographics
NPI:1437253499
Name:COUNTRY MARKET PHARMACIES LLC
Entity Type:Organization
Organization Name:COUNTRY MARKET PHARMACIES LLC
Other - Org Name:COUNTRY MARKET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR OF PHARMACY OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNDEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:517-937-4539
Mailing Address - Street 1:1410 W GANSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-4063
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1335 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SALINE
Practice Address - State:MI
Practice Address - Zip Code:48176-8730
Practice Address - Country:US
Practice Address - Phone:734-944-6702
Practice Address - Fax:734-944-3228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010081873336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2361789Medicaid
2361789OtherNCPDP PROVIDER IDENTIFICATION NUMBER
P00433595Medicare PIN
0P48130Medicare PIN
MI2361789Medicaid