Provider Demographics
NPI:1861497877
Name:LIPPERT ENTERPRISES INC
Entity Type:Organization
Organization Name:LIPPERT ENTERPRISES INC
Other - Org Name:EVANS DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:ISERHOTH
Authorized Official - Suffix:III
Authorized Official - Credentials:RPH
Authorized Official - Phone:989-828-6057
Mailing Address - Street 1:P.O. BOX 69
Mailing Address - Street 2:EVANS DRUG STORE
Mailing Address - City:SHEPHERD
Mailing Address - State:MI
Mailing Address - Zip Code:48883
Mailing Address - Country:US
Mailing Address - Phone:989-828-6057
Mailing Address - Fax:989-828-6821
Practice Address - Street 1:257 W WRIGHT AVE
Practice Address - Street 2:EVANS DRUG STORE
Practice Address - City:SHEPHERD
Practice Address - State:MI
Practice Address - Zip Code:48883
Practice Address - Country:US
Practice Address - Phone:989-828-6057
Practice Address - Fax:989-828-6821
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIPPERT ENTERPRISES INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-16
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301008051183500000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2366739Medicaid
MI5363260001Medicare NSC
MI2366739Medicaid