Provider Demographics
NPI:1013626639
Name:HACKLEY PROFESSIONAL PHARMACY, INC
Entity Type:Organization
Organization Name:HACKLEY PROFESSIONAL PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZDYBEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:231-672-4899
Mailing Address - Street 1:1675 LEAHY ST STE 111
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-5538
Mailing Address - Country:US
Mailing Address - Phone:231-672-7822
Mailing Address - Fax:231-672-8425
Practice Address - Street 1:1675 LEAHY ST STE 111
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5538
Practice Address - Country:US
Practice Address - Phone:231-672-7822
Practice Address - Fax:231-672-8425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-22
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1497896351Medicaid