Provider Demographics
NPI:1467566364
Name:MYMICHIGAN MEDICAL CENTER ALPENA
Entity Type:Organization
Organization Name:MYMICHIGAN MEDICAL CENTER ALPENA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OUTPATIENT PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:HICKOK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:989-356-8079
Mailing Address - Street 1:4000 WELLNESS DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48670-0001
Mailing Address - Country:US
Mailing Address - Phone:989-356-8079
Mailing Address - Fax:989-356-8076
Practice Address - Street 1:1501 W CHISHOLM ST
Practice Address - Street 2:OUTPATIENT PHARMACY
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1401
Practice Address - Country:US
Practice Address - Phone:989-356-8079
Practice Address - Fax:989-356-8076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302021206183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2312128Medicaid
MI2312128Medicaid