Provider Demographics
NPI:1629388780
Name:BALDWIN PATTIE DRUG STORE LLC
Entity Type:Organization
Organization Name:BALDWIN PATTIE DRUG STORE LLC
Other - Org Name:PATTIE DRUG OF BALDWIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/RPH.
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAWCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:BS IN PHARMACY
Authorized Official - Phone:231-745-4697
Mailing Address - Street 1:868 MICHIGAN AVE
Mailing Address - Street 2:P.O. BOX 310
Mailing Address - City:BALDWIN
Mailing Address - State:MI
Mailing Address - Zip Code:49304-7123
Mailing Address - Country:US
Mailing Address - Phone:231-745-4697
Mailing Address - Fax:231-745-8640
Practice Address - Street 1:868 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:MI
Practice Address - Zip Code:49304-7123
Practice Address - Country:US
Practice Address - Phone:231-745-4697
Practice Address - Fax:231-745-8640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-07
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MI53010094563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2127743OtherPK
MI1629388780Medicaid
MI1629388780Medicaid