Provider Demographics
NPI:1285623900
Name:WESTERN MICHIGAN APOTHECARIES, INC
Entity type:Organization
Organization Name:WESTERN MICHIGAN APOTHECARIES, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:C
Authorized Official - Last Name:WITHERSPOON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:231-723-3545
Mailing Address - Street 1:328 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-1702
Mailing Address - Country:US
Mailing Address - Phone:231-723-3545
Mailing Address - Fax:231-723-9928
Practice Address - Street 1:328 1ST ST
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-1702
Practice Address - Country:US
Practice Address - Phone:231-723-3545
Practice Address - Fax:231-723-9928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301004951333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1940197 (2344276)Medicaid
2344276OtherNABP
0300090001Medicare ID - Type Unspecified