Provider Demographics
NPI:1578602520
Name:HACKLEY PROFESSIONAL PHARMACY
Entity Type:Organization
Organization Name:HACKLEY PROFESSIONAL PHARMACY
Other - Org Name:HACKLEY PHARMACY WHITEHALL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:CARLTON
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-728-5974
Mailing Address - Street 1:905 E COLBY ST
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49461-1262
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:905 E COLBY ST
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:MI
Practice Address - Zip Code:49461-1262
Practice Address - Country:US
Practice Address - Phone:231-728-5974
Practice Address - Fax:231-728-1604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X, 3336C0004X
MI18522183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2369153OtherNCPDP PROVIDER IDENTIFICATION NUMBER