Provider Demographics
NPI:1639243157
Name:PENNOCK PHARMACY, INC.
Entity Type:Organization
Organization Name:PENNOCK PHARMACY, INC.
Other - Org Name:PENNOCK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CERTIFIED PHARMACY TECHNICIAN
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:RISNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-945-1212
Mailing Address - Street 1:1005 W GREEN ST
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-1712
Mailing Address - Country:US
Mailing Address - Phone:269-948-3136
Mailing Address - Fax:269-948-3134
Practice Address - Street 1:1005 W GREEN ST
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-1712
Practice Address - Country:US
Practice Address - Phone:269-948-3136
Practice Address - Fax:269-948-3134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010047103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2040181OtherPK
MI1639243157Medicaid