Provider Demographics
NPI:1467740688
Name:MIKES FAMILY PHARMACY INC
Entity Type:Organization
Organization Name:MIKES FAMILY PHARMACY INC
Other - Org Name:MIKES FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-740-6025
Mailing Address - Street 1:8718 WATER ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MONTAGUE
Mailing Address - State:MI
Mailing Address - Zip Code:49437-1204
Mailing Address - Country:US
Mailing Address - Phone:231-894-8633
Mailing Address - Fax:231-893-3530
Practice Address - Street 1:8718 WATER ST STE A
Practice Address - Street 2:
Practice Address - City:MONTAGUE
Practice Address - State:MI
Practice Address - Zip Code:49437-1204
Practice Address - Country:US
Practice Address - Phone:231-894-8633
Practice Address - Fax:231-893-3530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-21
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010097493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1467740688Medicaid
2375752OtherNCPDP PROVIDER IDENTIFICATION NUMBER