Provider Demographics
NPI:1740372663
Name:MUNSON HEALTHCARE CADILLAC
Entity type:Organization
Organization Name:MUNSON HEALTHCARE CADILLAC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP, ANCILLARY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LARAIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-392-8410
Mailing Address - Street 1:400 HOBART ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2331
Mailing Address - Country:US
Mailing Address - Phone:231-876-7374
Mailing Address - Fax:231-876-7498
Practice Address - Street 1:400 HOBART ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2331
Practice Address - Country:US
Practice Address - Phone:231-876-7374
Practice Address - Fax:231-876-7894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010106273336C0003X, 3336C0003X
3336I0012X
MI53010024603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2152752OtherPK
MI4991460Medicaid
MI5315068610OtherCONTROLLED SUBSTANCE LICENS
2040743OtherPK