Provider Demographics
NPI:1568562833
Name:CADILLAC FAMILY PHARMACY LLC
Entity Type:Organization
Organization Name:CADILLAC FAMILY PHARMACY LLC
Other - Org Name:CADILLAC FAMILY PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:231-775-8200
Mailing Address - Street 1:108 N MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:108 N MITCHELL ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2713
Practice Address - Country:US
Practice Address - Phone:231-775-8200
Practice Address - Fax:231-775-8099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010070263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2360092Medicaid
2360092OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1285800001Medicare NSC