Provider Demographics
NPI:1982701868
Name:HOMETOWN PHARMACY INC
Entity Type:Organization
Organization Name:HOMETOWN PHARMACY INC
Other - Org Name:WADHAMS PHARMACY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:REBEKAH
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:DESARMO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-861-6900
Mailing Address - Street 1:4171 S OCEANA DR
Mailing Address - Street 2:
Mailing Address - City:NEW ERA
Mailing Address - State:MI
Mailing Address - Zip Code:49446-9781
Mailing Address - Country:US
Mailing Address - Phone:231-861-6900
Mailing Address - Fax:231-861-7177
Practice Address - Street 1:5277 LAPEER RD
Practice Address - Street 2:
Practice Address - City:KIMBALL
Practice Address - State:MI
Practice Address - Zip Code:48074
Practice Address - Country:US
Practice Address - Phone:810-984-8200
Practice Address - Fax:810-984-1633
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOMETOWN PHARMACY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336L0003X
MI53010035743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1982701868OtherNPI
MI0799520004OtherROSTER BILLER
2330102OtherNCPDP