Provider Demographics
NPI:1124169081
Name:HACKLEY PHARMACY MUSKEGON HTS
Entity type:Organization
Organization Name:HACKLEY PHARMACY MUSKEGON HTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:CARTER
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-728-5974
Mailing Address - Street 1:2700 BAKER ST
Mailing Address - Street 2:ROBERT A WARREN BLDG
Mailing Address - City:MUSKEGON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:49444-2157
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2700 BAKER ST
Practice Address - Street 2:ROBERT A WARREN BLDG
Practice Address - City:MUSKEGON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:49444-2157
Practice Address - Country:US
Practice Address - Phone:231-737-9510
Practice Address - Fax:231-739-0837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X, 3336C0003X
MI5301006384333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2355510OtherOTHER ID NUMBER-COMMERCIAL NUMBER
2355510OtherOTHER ID NUMBER
MI3222835Medicaid