Provider Demographics
NPI:1992801625
Name:PROFESSIONAL PHARMACY INC
Entity type:Organization
Organization Name:PROFESSIONAL PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAREDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-891-1116
Mailing Address - Street 1:9175 CHERRY VALLEY AVE SE
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316-9746
Mailing Address - Country:US
Mailing Address - Phone:616-891-1116
Mailing Address - Fax:616-891-0080
Practice Address - Street 1:9175 CHERRY VALLEY AVE SE
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-9746
Practice Address - Country:US
Practice Address - Phone:616-891-1116
Practice Address - Fax:616-891-0080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
MI53010043033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2339679Medicaid
MI2339679Medicaid