Provider Demographics
NPI:1689053258
Name:MCBAIN FAMILY PHARMACY PLLC
Entity Type:Organization
Organization Name:MCBAIN FAMILY PHARMACY PLLC
Other - Org Name:LC FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER,AO
Authorized Official - Prefix:
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:
Authorized Official - Last Name:GILDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-559-0005
Mailing Address - Street 1:PO BOX 56
Mailing Address - Street 2:
Mailing Address - City:MC BAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49657-0056
Mailing Address - Country:US
Mailing Address - Phone:231-559-0005
Mailing Address - Fax:231-559-0004
Practice Address - Street 1:57 N MOREY RD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MI
Practice Address - Zip Code:49651-8585
Practice Address - Country:US
Practice Address - Phone:231-559-0005
Practice Address - Fax:231-559-0004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-28
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MI53010106833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2152214OtherPK