Provider Demographics
NPI:1942580972
Name:PIONEER PHARMACY CONSULTING LLC
Entity Type:Organization
Organization Name:PIONEER PHARMACY CONSULTING LLC
Other - Org Name:GREAT LAKES PHARMACY OF MIDLAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:989-615-7212
Mailing Address - Street 1:1120 EASTMAN AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-4215
Mailing Address - Country:US
Mailing Address - Phone:989-835-7911
Mailing Address - Fax:989-835-6975
Practice Address - Street 1:1120 EASTMAN AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4215
Practice Address - Country:US
Practice Address - Phone:989-835-7911
Practice Address - Fax:989-835-6975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-22
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MI53010096423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1942580972Medicaid
2131633OtherPK
MI1942580972Medicaid