Provider Demographics
NPI:1528019072
Name:NORTHGATE PHARMACY
Entity Type:Organization
Organization Name:NORTHGATE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:VOLK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:989-269-8061
Mailing Address - Street 1:721 N VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:BAD AXE
Mailing Address - State:MI
Mailing Address - Zip Code:48413-9188
Mailing Address - Country:US
Mailing Address - Phone:989-269-8061
Mailing Address - Fax:989-269-9189
Practice Address - Street 1:721 N VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:BAD AXE
Practice Address - State:MI
Practice Address - Zip Code:48413-9188
Practice Address - Country:US
Practice Address - Phone:989-269-8061
Practice Address - Fax:989-269-2094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301007690332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540C210260OtherBLUE CROSS BLUE SHIELD
MI874741850Medicaid
MI874741850Medicaid
MI540C210260OtherBLUE CROSS BLUE SHIELD