Provider Demographics
NPI:1982650420
Name:HOMETOWN PHARMACY INC.
Entity Type:Organization
Organization Name:HOMETOWN PHARMACY INC.
Other - Org Name:HOMETOWN PHARMACY #48 - MISHAWAKA
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:
Authorized Official - Phone:231-652-7810
Mailing Address - Street 1:606 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-6620
Mailing Address - Country:US
Mailing Address - Phone:574-255-2988
Mailing Address - Fax:574-258-5945
Practice Address - Street 1:606 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-6620
Practice Address - Country:US
Practice Address - Phone:574-255-2988
Practice Address - Fax:574-258-5945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336L0003X
IN60006398A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146914OtherPK
0748730001Medicare ID - Type Unspecified
INTA6010Medicare PIN