Provider Demographics
NPI:1306987268
Name:HACKLEY PHARMACY-WOLF LAKE
Entity type:Organization
Organization Name:HACKLEY PHARMACY-WOLF LAKE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RETAIL PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:DEBRUIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:231-728-4046
Mailing Address - Street 1:5483 E APPLE AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-3070
Mailing Address - Country:US
Mailing Address - Phone:231-788-4087
Mailing Address - Fax:231-788-3090
Practice Address - Street 1:5483 E APPLE AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-3070
Practice Address - Country:US
Practice Address - Phone:231-788-4087
Practice Address - Fax:231-788-3090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010053013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2643897Medicaid
2040771OtherPK