Provider Demographics
NPI:1811081979
Name:HEMMINGSEN DRUG STORE INC
Entity type:Organization
Organization Name:HEMMINGSEN DRUG STORE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:B
Authorized Official - Last Name:DILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:269-781-3411
Mailing Address - Street 1:132 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-1522
Mailing Address - Country:US
Mailing Address - Phone:269-781-3411
Mailing Address - Fax:269-781-2579
Practice Address - Street 1:132 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-1522
Practice Address - Country:US
Practice Address - Phone:269-781-3411
Practice Address - Fax:269-781-2579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010077853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2304234Medicaid
IN200372460AMedicaid
MI4838636Medicaid
MI540A310920OtherBLUE CROSS DME
IN200372460AMedicaid