Provider Demographics
NPI:1578670410
Name:HOMETOWN PHARMACY INC
Entity Type:Organization
Organization Name:HOMETOWN PHARMACY INC
Other - Org Name:HOMETOWN PHARMACY #51 - GRAND RAPIDS
Other - Org Type:Doing Business As
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:
Authorized Official - Phone:231-652-7810
Mailing Address - Street 1:4252 KALAMAZOO AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-3607
Mailing Address - Country:US
Mailing Address - Phone:616-281-1323
Mailing Address - Fax:616-281-1330
Practice Address - Street 1:4252 KALAMAZOO AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-3607
Practice Address - Country:US
Practice Address - Phone:616-281-1323
Practice Address - Fax:616-281-1330
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOMETOWN PHARMACY INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-24
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X, 3336S0011X
MI53010108973336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2158175OtherPK
2158175OtherPK
MI5301007002OtherLICENSE #