Provider Demographics
NPI:1104992734
Name:DELTON FAMILY PHARMACY INC
Entity type:Organization
Organization Name:DELTON FAMILY PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:269-623-5250
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:DELTON
Mailing Address - State:MI
Mailing Address - Zip Code:49046-0190
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:338 N GROVE ST
Practice Address - Street 2:
Practice Address - City:DELTON
Practice Address - State:MI
Practice Address - Zip Code:49046-9601
Practice Address - Country:US
Practice Address - Phone:269-623-5250
Practice Address - Fax:269-623-5140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010080763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5363120001Medicare NSC