Provider Demographics
NPI:1992735666
Name:PORTAGE PHARMACY, INC.
Entity type:Organization
Organization Name:PORTAGE PHARMACY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:CURTIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:269-327-0033
Mailing Address - Street 1:7966 LOVERS LN
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-4446
Mailing Address - Country:US
Mailing Address - Phone:269-327-0033
Mailing Address - Fax:269-327-2709
Practice Address - Street 1:7966 LOVERS LN
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-4446
Practice Address - Country:US
Practice Address - Phone:269-327-0033
Practice Address - Fax:269-327-2709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301002930333600000X
PANP0007983336C0003X
WI1994-433336C0003X
OHNRP.022791200-033336C0003X
NY0357243336C0003X
IL054.0178423336C0003X
IN64002337A3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2527217Medicaid
2040070OtherPK