Provider Demographics
NPI:1972558104
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:
Authorized Official - Phone:231-652-7810
Mailing Address - Street 1:4000 EASTERN SKY DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7351
Mailing Address - Country:US
Mailing Address - Phone:231-947-6921
Mailing Address - Fax:231-947-4579
Practice Address - Street 1:4000 EASTERN SKY DR
Practice Address - Street 2:SUITE 1
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7351
Practice Address - Country:US
Practice Address - Phone:231-947-6921
Practice Address - Fax:231-947-4579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
MI53010102233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2142382OtherPK
MI1972558104Medicaid
MI1975631Medicaid