Provider Demographics
NPI:1487793436
Name:HACKLEY PHARMACY NORTON SHORES
Entity type:Organization
Organization Name:HACKLEY PHARMACY NORTON SHORES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:CARLTON
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-728-5974
Mailing Address - Street 1:3535 PARK ST
Mailing Address - Street 2:STE 104
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-3736
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3535 PARK ST
Practice Address - Street 2:STE 104
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-3736
Practice Address - Country:US
Practice Address - Phone:231-739-9302
Practice Address - Fax:231-728-1604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 3336I0012X
MI53010085443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2369165OtherOTHER ID NUMBER
MI2369165Medicaid
2369165OtherOTHER ID NUMBER-COMMERCIAL NUMBER