Provider Demographics
NPI:1821045964
Name:BELFY DRUG STORE INC
Entity Type:Organization
Organization Name:BELFY DRUG STORE INC
Other - Org Name:MAIN STREET PHARMACY AND GIFTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SOEKARMOEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:269-649-1476
Mailing Address - Street 1:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:WATERVLIET
Mailing Address - State:MI
Mailing Address - Zip Code:49098-0097
Mailing Address - Country:US
Mailing Address - Phone:269-637-1161
Mailing Address - Fax:269-639-2524
Practice Address - Street 1:387 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERVLIET
Practice Address - State:MI
Practice Address - Zip Code:49098-9795
Practice Address - Country:US
Practice Address - Phone:269-463-3164
Practice Address - Fax:269-639-2524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MI53010079513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1964404Medicaid
2320769OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MI871970152Medicaid
MI1964404Medicaid