Provider Demographics
NPI:1538426093
Name:PENNOCK PHARMACY
Entity type:Organization
Organization Name:PENNOCK PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED PHARMACY TECHNICIAN
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:RISNER
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:269-945-1212
Mailing Address - Street 1:12851 W M 179 HWY
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49348-9318
Mailing Address - Country:US
Mailing Address - Phone:269-945-8050
Mailing Address - Fax:269-945-8048
Practice Address - Street 1:12851 W M 179 HWY
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MI
Practice Address - Zip Code:49348-9318
Practice Address - Country:US
Practice Address - Phone:269-945-8050
Practice Address - Fax:269-945-8048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-20
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010098003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2134742OtherPK