1255738746 NPI number — PGPA, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255738746 NPI number — PGPA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PGPA, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BENTON HARBOR COMMUNITY PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255738746
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3544 MERIDIAN CROSSINGS
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
OKEMOS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48864-6025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-381-7472
Provider Business Mailing Address Fax Number:
517-381-8724

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 M 139
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTON HARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49022-3881
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-849-8251
Provider Business Practice Location Address Fax Number:
269-927-2515
Provider Enumeration Date:
11/26/2014

Additional Information

Authorized Official

Authorized Official Last Name:
ADRIAN-ROBERTS
Authorized Official First Name:
LYNNE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
517-381-7472

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 5301010603 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2149003 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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