Organization
PONTIAC TRAIL PHARMACY INC
Active
Other names
Pontiac Trail Medical Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
MR. CARL ROBERT HENDRICKS R.PH (OWNER/R.PH.)
(248) 669-2776
Entity
Organization
Contact information
Practice address
620 N. PONTIAC TRAIL, WALLED LAKE, MI 48390
(248) 669-2776
(248) 669-2835
Mailing address
43155 W. NINE MILE RD., NOVI, MI 48376-8026
Taxonomy
Speciality
Code
Description
License number
State
261QH0100X
Health Service Clinic/Center
—
—
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
5301004197
MI
3336L0003X
Long Term Care Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1649484
—
MI
05
—
1665835
—
MI
01
—
2338689
OTHER ID NUMBER
—
05
—
2338689
—
MI
Enumeration date
08/27/2006
Last updated
08/01/2017
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