Provider Demographics
NPI:1255378055
Name:FLINT FAMILY PHARMACY LLC
Entity type:Organization
Organization Name:FLINT FAMILY PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-339-9008
Mailing Address - Street 1:11271 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:FARWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48622-9439
Mailing Address - Country:US
Mailing Address - Phone:989-339-9008
Mailing Address - Fax:855-855-4919
Practice Address - Street 1:G4444 FENTON RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-3784
Practice Address - Country:US
Practice Address - Phone:810-235-7995
Practice Address - Fax:810-235-0241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2020-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010020903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2040869OtherPK
MI2535586Medicaid
0187200001Medicare NSC