Blue Water Pharmacy LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

5301009241 Issued in MI

Legal business name

BLUE WATER PHARMACY LLC

Practice address

1524 10TH Street
Port Huron, MI 48060

Phone

(813) 982-3100

Fax

(810) 982-3106

NPI assigned

Nov 10, 2009

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Manish Patel

Title

Owner

Phone

(813) 304-2221

Specialties & licenses 3

Addresses

Other identifiers 1

Other names 1

• Blue Water Pharmacy Former legal business name

Medicare fee-for-service enrollment

Enrolled in MI

Enrollment records 1

Tax ID family

Blue Water Pharmacy2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Blue Water Pharmacy LLC

  • Long Term Care Pharmacy
  • Port Huron, MI
  • NPI 1568091957
  NPD tax ID

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Kimberly Ann Cowhy, R.PH

  • Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
  • Port Huron, MI
  • NPI 1629145131
  NPD
• Malla Mitta, RPH

  • Pharmacist
  • Port Huron, MI
  • NPI 1942871876
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1257811200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1687132800000",
    "number": "1598092769",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1524 10TH STREET",
            "city": "PORT HURON",
            "state": "MI",
            "postal_code": "48060",
            "telephone_number": "813-982-3100",
            "fax_number": "810-982-3106"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1524 10TH STREET",
            "city": "PORT HURON",
            "state": "MI",
            "postal_code": "48060",
            "telephone_number": "813-982-3100",
            "fax_number": "810-982-3106"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLUE WATER PHARMACY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-11-10",
        "last_updated": "2023-06-19",
        "certification_date": "2023-06-19",
        "status": "A",
        "authorized_official_last_name": "PATEL",
        "authorized_official_first_name": "MANISH",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "813-304-2221"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "MI",
            "license": "5301009241",
            "primary": true
        },
        {
            "code": "3336C0004X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Compounding Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336S0011X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Specialty Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2122665",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Blue Water Pharmacy",
            "code": "4",
            "type": "Former Legal Business Name"
        },
        {
            "organization_name": "Blue Water Pharmacy",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

• Blue Water Medical Massage PLLC
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• Blue Water Oncology PC
• Blue Water Pharmacy LLC
• Blue Water Physical Therapy, Inc.
• Blue Water Podiatry PC
• Blue Water Rad Onc, LLC
• Blue Water Thoracic and Cardiovascular Surgery, PLC
• Blue Water Urgent Care Port Huron

• Community/Retail Pharmacy in Port Huron, MI
• Providers in Port Huron, MI by specialty
• Community/Retail Pharmacy in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 19, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.