Provider Demographics
NPI:1730291725
Name:SIXTH STREET DRUGS INC
Entity Type:Organization
Organization Name:SIXTH STREET DRUGS INC
Other - Org Name:SIXTH STREET DRUG INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP, ANCILLARY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LARAIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-392-8410
Mailing Address - Street 1:1020 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2302
Mailing Address - Country:US
Mailing Address - Phone:231-946-4570
Mailing Address - Fax:231-946-2920
Practice Address - Street 1:1020 SIXTH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2302
Practice Address - Country:US
Practice Address - Phone:231-946-4570
Practice Address - Fax:231-946-2920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MI53010011933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1730291725Medicaid
2041162OtherPK