Provider Demographics
NPI:1205915931
Name:FREEDOM APOTHECARY, INC.
Entity type:Organization
Organization Name:FREEDOM APOTHECARY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EINAR
Authorized Official - Middle Name:B
Authorized Official - Last Name:TJOLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:517-263-7300
Mailing Address - Street 1:905 N MAIN ST
Mailing Address - Street 2:#4
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-2168
Mailing Address - Country:US
Mailing Address - Phone:517-273-7300
Mailing Address - Fax:517-263-7370
Practice Address - Street 1:905 N MAIN ST
Practice Address - Street 2:#4
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-2168
Practice Address - Country:US
Practice Address - Phone:517-273-7300
Practice Address - Fax:517-263-7370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010062543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MINABPOther2327535
MIBM4390580OtherDEA #
MIBM4390580OtherDEA #