Provider Demographics
NPI:1619272457
Name:EAGLE PHARMACY OF FARWELL PC
Entity Type:Organization
Organization Name:EAGLE PHARMACY OF FARWELL PC
Other - Org Name:EAGLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-339-9008
Mailing Address - Street 1:11271 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:FARWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48622-9439
Mailing Address - Country:US
Mailing Address - Phone:989-339-9008
Mailing Address - Fax:855-855-4919
Practice Address - Street 1:109 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FARWELL
Practice Address - State:MI
Practice Address - Zip Code:48622-9553
Practice Address - Country:US
Practice Address - Phone:989-588-2900
Practice Address - Fax:989-588-2901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-25
Last Update Date:2023-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010094953336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2374875OtherNCPDP PROVIDER IDENTIFICATION NUMBER