Provider Demographics
NPI:1689601916
Name:PAW PAW VILLAGE DRUG, INC.
Entity Type:Organization
Organization Name:PAW PAW VILLAGE DRUG, INC.
Other - Org Name:PAW PAW VILLAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CERTIFIED TECHNICIAN
Authorized Official - Prefix:MISS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED TECH
Authorized Official - Phone:269-657-6073
Mailing Address - Street 1:322 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-1408
Mailing Address - Country:US
Mailing Address - Phone:269-657-6073
Mailing Address - Fax:269-655-1643
Practice Address - Street 1:322 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1408
Practice Address - Country:US
Practice Address - Phone:269-657-6073
Practice Address - Fax:269-655-1643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010037403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2332839Medicaid
MI2332839OtherNCPDP NUMBER
MI2332839OtherNCPDP NUMBER