Provider Demographics
NPI:1477520377
Name:S. FOUNTAIN'S INC
Entity Type:Organization
Organization Name:S. FOUNTAIN'S INC
Other - Org Name:DBA THE MEDICINE SHOPPE #1189
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRES
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:FOUNTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:989-362-7415
Mailing Address - Street 1:133 NEWMAN ST
Mailing Address - Street 2:
Mailing Address - City:EAST TAWAS
Mailing Address - State:MI
Mailing Address - Zip Code:48730
Mailing Address - Country:US
Mailing Address - Phone:989-362-7415
Mailing Address - Fax:989-362-0597
Practice Address - Street 1:133 NEWMAN ST
Practice Address - Street 2:
Practice Address - City:EAST TAWAS
Practice Address - State:MI
Practice Address - Zip Code:48730
Practice Address - Country:US
Practice Address - Phone:989-362-7415
Practice Address - Fax:989-362-0597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3336C0003X
MI5301005681183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2803829Medicaid
MI2803794Medicaid
MI2349517OtherNABP
MI2349517OtherNABP
MIBT3035056OtherDEA #
MI0745450001Medicare NSC
MI2349517OtherNABP