Provider Demographics
NPI:1912017310
Name:PATTIE DRUG OF BALDWIN INC
Entity Type:Organization
Organization Name:PATTIE DRUG OF BALDWIN INC
Other - Org Name:PATTIE DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:TENNIS
Authorized Official - Middle Name:PATTIE
Authorized Official - Last Name:TRUCKS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:231-745-4697
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:MI
Mailing Address - Zip Code:49304
Mailing Address - Country:US
Mailing Address - Phone:231-745-4697
Mailing Address - Fax:231-745-8640
Practice Address - Street 1:868 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:MI
Practice Address - Zip Code:49304-0310
Practice Address - Country:US
Practice Address - Phone:231-745-4697
Practice Address - Fax:231-745-8640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301004991183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23444Z8Medicaid
MI23444Z8OtherNABP
MI23444Z8OtherNABP