Provider Demographics
NPI:1467534255
Name:HURON STREET PHARMACY
Entity Type:Organization
Organization Name:HURON STREET PHARMACY
Other - Org Name:ADVANCED PHARMACY AND NUTRITION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:810-688-3090
Mailing Address - Street 1:PO BOX 319
Mailing Address - Street 2:
Mailing Address - City:NORTH BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48461-0319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3960 HURON ST
Practice Address - Street 2:
Practice Address - City:NORTH BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48461-6122
Practice Address - Country:US
Practice Address - Phone:810-668-3090
Practice Address - Fax:810-688-3791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL977292333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3521208Medicaid
2304880OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MI3521208Medicaid