Provider Demographics
NPI:1124163753
Name:FREEDOM APOTHECARY INC
Entity type:Organization
Organization Name:FREEDOM APOTHECARY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:EINAR
Authorized Official - Middle Name:B
Authorized Official - Last Name:TJOLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:517-467-7225
Mailing Address - Street 1:PO BOX 346
Mailing Address - Street 2:
Mailing Address - City:ONSTED
Mailing Address - State:MI
Mailing Address - Zip Code:49265-0346
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 N MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:ONSTED
Practice Address - State:MI
Practice Address - Zip Code:49265-9202
Practice Address - Country:US
Practice Address - Phone:517-467-7225
Practice Address - Fax:517-467-4718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53150127283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2350611OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MI2876941Medicaid
MI2876941Medicaid
MIBM8168583OtherDEA #