Provider Demographics
NPI:1720322159
Name:HEMLOCK PHARMACY LLC
Entity Type:Organization
Organization Name:HEMLOCK PHARMACY LLC
Other - Org Name:HEMLOCK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARM.D/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-301-0250
Mailing Address - Street 1:PO BOX 617
Mailing Address - Street 2:
Mailing Address - City:HEMLOCK
Mailing Address - State:MI
Mailing Address - Zip Code:48626
Mailing Address - Country:US
Mailing Address - Phone:989-301-0250
Mailing Address - Fax:989-301-0240
Practice Address - Street 1:132 HEMLOCK PLAZA DR
Practice Address - Street 2:
Practice Address - City:HEMLOCK
Practice Address - State:MI
Practice Address - Zip Code:48626-9544
Practice Address - Country:US
Practice Address - Phone:989-301-0250
Practice Address - Fax:989-301-0240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-26
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010099573336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2377388Medicaid
2136745OtherPK