Provider Demographics
NPI:1821189598
Name:BELLAIRE PHARMACY INC
Entity Type:Organization
Organization Name:BELLAIRE PHARMACY INC
Other - Org Name:BELLAIRE PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:FIFELSKI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:231-533-8014
Mailing Address - Street 1:PO BOX 272
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:MI
Mailing Address - Zip Code:49615-0272
Mailing Address - Country:US
Mailing Address - Phone:231-533-8014
Mailing Address - Fax:231-533-6697
Practice Address - Street 1:120 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:MI
Practice Address - Zip Code:49615-5105
Practice Address - Country:US
Practice Address - Phone:231-533-8014
Practice Address - Fax:231-533-6697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010056943336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2042060OtherPK
MI2861813Medicaid