# COUNTRY SQUIRE DISCOUNT PHCY INC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** COUNTRY SQUIRE LTC PHCY
- **Organization subpart:** No

## Provider details

- **NPI number:** 1871548610
- **Authorized official:** JUDSON AFMAN RPH (MEMBER)
- **Authorized official phone:** (231) 924-2120

## Contact information

- **Practice address:** 26 E MAIN ST, STE B, FREMONT, MI 49412-1244
- **Practice address phone:** (231) 924-2120
- **Practice address fax:** (231) 924-6310
- **Mailing address:** 26 E MAIN ST, STE B, FREMONT, MI 49412-1244
- **Mailing address phone:** (231) 924-2120
- **Mailing address fax:** (231) 924-6310

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 3336L0003X | Long Term Care Pharmacy | 53010008387 | MI | Yes |

## Other

- **Enumeration date:** 05/23/2006
- **Last updated:** 09/15/2010

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 2368264 | NCPDP PROVIDER IDENTIFICATION NUMBER | — |