Basic Information
| Provider Information | |||||||||
| NPI: | 1184096653 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHARMACY COUNTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2655 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194731493 | ||||||||
| FaxNumber: | 4194747137 | ||||||||
| Practice Location | |||||||||
| Address1: | 1070 N MONROE ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481623113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342408888 | ||||||||
| FaxNumber: | 7342408899 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2015 | ||||||||
| LastUpdateDate: | 04/12/2018 | ||||||||
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| AuthorizedOfficialLastName: | CROSS | ||||||||
| AuthorizedOfficialFirstName: | MISSY | ||||||||
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| AuthorizedOfficialTitleorPosition: | GENERAL MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4194731493 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROMEDICA PHYSICIANS GROUP, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | MI | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 1184096653 | 05 | MI | MEDICAID |