Provider Demographics
NPI:1215014311
Name:HOMETOWN PHARMACY INC
Entity type:Organization
Organization Name:HOMETOWN PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:REBEKAH
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:DESARMO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D, MBA
Authorized Official - Phone:231-861-6902
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 1:178 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:MI
Practice Address - Zip Code:49455-1028
Practice Address - Country:US
Practice Address - Phone:231-861-4341
Practice Address - Fax:231-861-6609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336S0011X
MI53010056843336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1215014311Medicaid
2119693OtherPK
2349822OtherNCPDP PROVIDER IDENTIFICATION NUMBER