Provider Demographics
NPI:1578583175
Name:KINGSLEY PHARMACY AND COMPOUNDING CENTER INC
Entity Type:Organization
Organization Name:KINGSLEY PHARMACY AND COMPOUNDING CENTER INC
Other - Org Name:KINGSLEY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:REUTHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-263-7701
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:KINGSLEY
Mailing Address - State:MI
Mailing Address - Zip Code:49649-0247
Mailing Address - Country:US
Mailing Address - Phone:231-263-7701
Mailing Address - Fax:231-263-7925
Practice Address - Street 1:114 S BROWNSON AVE
Practice Address - Street 2:
Practice Address - City:KINGSLEY
Practice Address - State:MI
Practice Address - Zip Code:49649-5103
Practice Address - Country:US
Practice Address - Phone:231-263-7701
Practice Address - Fax:231-263-7925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010106713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2152347OtherPK
MI0424050001Medicare NSC