Provider Demographics
NPI:1851459077
Name:COUNTRYSIDE DRUG COMPANY III
Entity Type:Organization
Organization Name:COUNTRYSIDE DRUG COMPANY III
Other - Org Name:COUNTRYSIDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANG
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEAL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:989-427-5141
Mailing Address - Street 1:PO BOX 197
Mailing Address - Street 2:
Mailing Address - City:EDMORE
Mailing Address - State:MI
Mailing Address - Zip Code:48829-0197
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:503 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EDMORE
Practice Address - State:MI
Practice Address - Zip Code:48829-9709
Practice Address - Country:US
Practice Address - Phone:989-427-5141
Practice Address - Fax:989-427-5142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010052143336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2040614OtherPK
MI2606436Medicaid