Provider Demographics
NPI:1922163351
Name:HOMETOWN PHARMACY INC
Entity Type:Organization
Organization Name:HOMETOWN PHARMACY INC
Other - Org Name:HOMETOWN PHARMACY #54 - OXFORD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE OPERATIONS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:REBEKAH
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:DESARMO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D, MBA
Authorized Official - Phone:231-652-7810
Mailing Address - Street 1:1 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-4978
Mailing Address - Country:US
Mailing Address - Phone:248-628-2538
Mailing Address - Fax:248-628-0721
Practice Address - Street 1:1 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MI
Practice Address - Zip Code:48371-4978
Practice Address - Country:US
Practice Address - Phone:248-628-2538
Practice Address - Fax:248-628-0721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
MI53010109633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1922163351Medicaid
2160289OtherPK