Provider Demographics
NPI:1912942111
Name:HOMETOWN PHARMACY INC
Entity type:Organization
Organization Name:HOMETOWN PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE OPERATIONS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:REBEKAH
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:DESARMO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D, MBA
Authorized Official - Phone:231-652-7810
Mailing Address - Street 1:11 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:MI
Mailing Address - Zip Code:49345-1718
Mailing Address - Country:US
Mailing Address - Phone:616-887-7323
Mailing Address - Fax:616-887-9559
Practice Address - Street 1:11 S STATE ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:MI
Practice Address - Zip Code:49345-1718
Practice Address - Country:US
Practice Address - Phone:616-887-7323
Practice Address - Fax:616-887-9559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MI53010083213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2040569OtherPK
MI2512518Medicaid
1120010019Medicare NSC