Provider Demographics
NPI:1770031957
Name:DUANE WATERS CORRECTIONAL PHARMACY
Entity Type:Organization
Organization Name:DUANE WATERS CORRECTIONAL PHARMACY
Other - Org Name:PHARMACORR
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:COURSER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:517-780-5474
Mailing Address - Street 1:3857 COOPER ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-7547
Mailing Address - Country:US
Mailing Address - Phone:517-780-5479
Mailing Address - Fax:
Practice Address - Street 1:3857 COOPER ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-7547
Practice Address - Country:US
Practice Address - Phone:517-780-5479
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2400XAmbulatory Health Care FacilitiesClinic/CenterPrison Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIFD6016453OtherDEA