Provider Demographics
NPI:1497896351
Name:HACKLEY PROFESSIONAL PHARMACY, INC
Entity Type:Organization
Organization Name:HACKLEY PROFESSIONAL PHARMACY, INC
Other - Org Name:HACKLEY PROFESSIONAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:NAGENGAST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-728-1950
Mailing Address - Street 1:1675 LEAHY ST
Mailing Address - Street 2:SUITE 111
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-5500
Mailing Address - Country:US
Mailing Address - Phone:231-672-7822
Mailing Address - Fax:231-728-4093
Practice Address - Street 1:1675 LEAHY ST
Practice Address - Street 2:SUITE 111
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5500
Practice Address - Country:US
Practice Address - Phone:231-672-7822
Practice Address - Fax:231-728-4093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010052763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2042183OtherPK