Provider Demographics
NPI:1245297415
Name:ST CHARLES PHARMACY LLC
Entity type:Organization
Organization Name:ST CHARLES PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:989-865-9971
Mailing Address - Street 1:1008 N SAGINAW ST
Mailing Address - Street 2:
Mailing Address - City:ST. CHARLES
Mailing Address - State:MI
Mailing Address - Zip Code:48655
Mailing Address - Country:US
Mailing Address - Phone:989-865-9971
Mailing Address - Fax:989-865-6216
Practice Address - Street 1:1008 N SAGINAW ST
Practice Address - Street 2:
Practice Address - City:ST. CHARLES
Practice Address - State:MI
Practice Address - Zip Code:48655
Practice Address - Country:US
Practice Address - Phone:989-865-9971
Practice Address - Fax:989-865-6216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-29
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0133410001Medicare NSC