Provider Demographics
NPI:1558901124
Name:HOME TOWN PHARMACY INC
Entity Type:Organization
Organization Name:HOME TOWN PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE OPERATIONS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:REBEKAH
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:DESARMO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D, MBA
Authorized Official - Phone:231-652-7810
Mailing Address - Street 1:PO BOX 884
Mailing Address - Street 2:
Mailing Address - City:NEWAYGO
Mailing Address - State:MI
Mailing Address - Zip Code:49337-0884
Mailing Address - Country:US
Mailing Address - Phone:231-652-7810
Mailing Address - Fax:231-652-7876
Practice Address - Street 1:110 S CLINTON ST
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:MI
Practice Address - Zip Code:49285-9148
Practice Address - Country:US
Practice Address - Phone:517-851-7575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOME TOWN PHARMACY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5301007836OtherBOARD OF PHARMACY LICENSE
MI5315016511OtherCONTROLLED SUBSTANCE