Provider Demographics
NPI:1770595670
Name:MODEL DRUG STORE
Entity type:Organization
Organization Name:MODEL DRUG STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:616-392-4707
Mailing Address - Street 1:35 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-3102
Mailing Address - Country:US
Mailing Address - Phone:616-392-4707
Mailing Address - Fax:616-392-2449
Practice Address - Street 1:35 W 8TH ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3102
Practice Address - Country:US
Practice Address - Phone:616-392-4707
Practice Address - Fax:616-392-2449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010020433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1697599Medicaid
2306303OtherNCPDP