Provider Demographics
NPI:1992810923
Name:CARMAN PHARMACY
Entity type:Organization
Organization Name:CARMAN PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:CARMEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-672-5543
Mailing Address - Street 1:1598 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:MI
Mailing Address - Zip Code:49070-5104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1598 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:MI
Practice Address - Zip Code:49070
Practice Address - Country:US
Practice Address - Phone:269-672-5543
Practice Address - Fax:269-672-5656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010051213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7973029Medicaid
2344517OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0686610001Medicare NSC