Provider Demographics
NPI:1790882629
Name:BATH PHARMACY INC
Entity Type:Organization
Organization Name:BATH PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARM
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STODDARD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:517-641-4332
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:MI
Mailing Address - Zip Code:48808-0280
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14043 WEBSTER RD
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:MI
Practice Address - Zip Code:48808-8711
Practice Address - Country:US
Practice Address - Phone:517-641-4332
Practice Address - Fax:517-641-6469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301003629333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2334059OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MI2542544Medicaid