Provider Demographics
NPI:1255518841
Name:HINKLEY DRUG STORE
Entity type:Organization
Organization Name:HINKLEY DRUG STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMSHACK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:231-734-3811
Mailing Address - Street 1:PO BOX 635
Mailing Address - Street 2:
Mailing Address - City:EVART
Mailing Address - State:MI
Mailing Address - Zip Code:49631-0635
Mailing Address - Country:US
Mailing Address - Phone:231-734-3811
Mailing Address - Fax:
Practice Address - Street 1:107 N MAIN
Practice Address - Street 2:
Practice Address - City:EVART
Practice Address - State:MI
Practice Address - Zip Code:49631
Practice Address - Country:US
Practice Address - Phone:231-734-3811
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-25
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302020377333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2315477OtherNABP
2315477OtherMEDICAID TYPE 50
MI4818929Medicaid
0F71003OtherBLUE CROSS OF MI
4482950001Medicare NSC
2315477OtherMEDICAID TYPE 50