Provider Demographics
NPI:1639180144
Name:OSCODA COMMUNITY PHARMACY
Entity Type:Organization
Organization Name:OSCODA COMMUNITY PHARMACY
Other - Org Name:OSCODA COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:QUISENBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-739-0020
Mailing Address - Street 1:5737 N US 23
Mailing Address - Street 2:STE 8
Mailing Address - City:OSCODA
Mailing Address - State:MI
Mailing Address - Zip Code:48750-8728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5737 N US 23
Practice Address - Street 2:STE 8
Practice Address - City:OSCODA
Practice Address - State:MI
Practice Address - Zip Code:48750-8728
Practice Address - Country:US
Practice Address - Phone:989-739-0020
Practice Address - Fax:989-739-0764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010046893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2342652Medicaid
2342652OtherNCPDP PROVIDER IDENTIFICATION NUMBER