Provider Demographics
NPI:1639133150
Name:HOMETOWN PHARMACY INC
Entity Type:Organization
Organization Name:HOMETOWN PHARMACY INC
Other - Org Name:SWANSTRA PHARMACY
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:PHARM D, MBA
Authorized Official - Phone:231-652-7810
Mailing Address - Street 1:3 W MONROE ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:MI
Mailing Address - Zip Code:49013-1351
Mailing Address - Country:US
Mailing Address - Phone:269-427-7706
Mailing Address - Fax:269-427-5752
Practice Address - Street 1:3 W MONROE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:MI
Practice Address - Zip Code:49013-1351
Practice Address - Country:US
Practice Address - Phone:269-427-7706
Practice Address - Fax:269-427-5752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MI53010084513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2042228OtherPK
MI4916115Medicaid
2042228OtherPK