Provider Demographics
NPI:1588600498
Name:THREE RIVERS VILLAGE PHARMACY
Entity type:Organization
Organization Name:THREE RIVERS VILLAGE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GEN MGR
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MURK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-637-1517
Mailing Address - Street 1:300 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-2376
Mailing Address - Country:US
Mailing Address - Phone:269-279-0465
Mailing Address - Fax:269-279-0425
Practice Address - Street 1:300 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-2376
Practice Address - Country:US
Practice Address - Phone:269-279-0465
Practice Address - Fax:269-279-0425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301007506333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI235486Medicaid
2363505OtherOTHER ID NUMBER-COMMERCIAL NUMBER