Provider Demographics
NPI:1477641926
Name:BOSTICK DRUG STORE INC
Entity Type:Organization
Organization Name:BOSTICK DRUG STORE INC
Other - Org Name:BOSTICKS DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:BOSTICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-824-3465
Mailing Address - Street 1:PO BOX 368
Mailing Address - Street 2:117 W MAIN ST
Mailing Address - City:MANTON
Mailing Address - State:MI
Mailing Address - Zip Code:49663
Mailing Address - Country:US
Mailing Address - Phone:231-824-6465
Mailing Address - Fax:
Practice Address - Street 1:117 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MANTON
Practice Address - State:MI
Practice Address - Zip Code:49663
Practice Address - Country:US
Practice Address - Phone:231-824-6465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0867880001Medicare NSC