Provider Demographics
NPI:1700887148
Name:THE COUNTRY SQUIRE DISCOUNT PHARMACY, INC
Entity Type:Organization
Organization Name:THE COUNTRY SQUIRE DISCOUNT PHARMACY, INC
Other - Org Name:COUNTRY SQUIRE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JUDSON
Authorized Official - Middle Name:K
Authorized Official - Last Name:AFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:231-924-2120
Mailing Address - Street 1:30 E MAIN
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49412-1244
Mailing Address - Country:US
Mailing Address - Phone:231-924-2120
Mailing Address - Fax:231-924-6310
Practice Address - Street 1:30 E MAIN
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-1244
Practice Address - Country:US
Practice Address - Phone:231-924-2120
Practice Address - Fax:231-924-6310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301001172332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540F210020OtherBCBS OF MI DME
MI87411545Medicaid
MI87411545Medicaid