Provider Demographics
NPI:1912914797
Name:KALAMAZOO LONG TERM CARE LLC
Entity type:Organization
Organization Name:KALAMAZOO LONG TERM CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:269-388-4850
Mailing Address - Street 1:PO BOX 87
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49083-0087
Mailing Address - Country:US
Mailing Address - Phone:269-388-4850
Mailing Address - Fax:269-388-4870
Practice Address - Street 1:1000 S BURDICK ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001-2734
Practice Address - Country:US
Practice Address - Phone:269-388-4850
Practice Address - Fax:269-388-4870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010084113336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2368505OtherNCPDP PROVIDER IDENTIFICATION NUMBER