Provider Demographics
NPI:1821104902
Name:HARDINGS GALESBURG MARKET INC
Entity Type:Organization
Organization Name:HARDINGS GALESBURG MARKET INC
Other - Org Name:HARDING'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSTAVSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-492-2919
Mailing Address - Street 1:3750 W CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4630
Mailing Address - Country:US
Mailing Address - Phone:269-323-7380
Mailing Address - Fax:269-323-7392
Practice Address - Street 1:3750 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4630
Practice Address - Country:US
Practice Address - Phone:269-323-7380
Practice Address - Fax:269-323-7392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301006958332B00000X, 333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2359695OtherNCPDP
MI87-4835868Medicaid
MI50-2359695Medicaid
MI50-2359695Medicaid
2359695OtherNCPDP