Provider Demographics
NPI:1902817414
Name:ELMERS PHARMACY INC
Entity Type:Organization
Organization Name:ELMERS PHARMACY INC
Other - Org Name:ELMER'S PHARMACY INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ELENICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-789-9200
Mailing Address - Street 1:412 N LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829-1365
Mailing Address - Country:US
Mailing Address - Phone:906-789-9200
Mailing Address - Fax:906-789-2118
Practice Address - Street 1:412 N LINCOLN RD
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1365
Practice Address - Country:US
Practice Address - Phone:906-789-9200
Practice Address - Fax:906-789-2118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010043863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2039403OtherPK
MI1731761Medicaid
MI2340420Medicaid