Provider Demographics
NPI:1487665725
Name:NORTHERN MICHIGAN UNIVERSITY
Entity Type:Organization
Organization Name:NORTHERN MICHIGAN UNIVERSITY
Other - Org Name:UNIVERSITY HEALTH CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-227-1605
Mailing Address - Street 1:1401 PRESQUE ISLE AVE
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2818
Mailing Address - Country:US
Mailing Address - Phone:906-227-1605
Mailing Address - Fax:906-227-2332
Practice Address - Street 1:1401 PRESQUE ISLE AVE
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2818
Practice Address - Country:US
Practice Address - Phone:906-227-2355
Practice Address - Fax:906-227-1332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010028403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1840167Medicaid
2040953OtherPK