Pontiac Trail Pharmacy Inc

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

5301004197 Issued in MI

Legal business name

PONTIAC TRAIL PHARMACY INC

Doing business as

Pontiac Trail Medical Pharmacy

Practice address

620 N. Pontiac Trail
Walled Lake, MI 48390

Phone

(248) 669-2776

Fax

(248) 669-2835

NPI assigned

Aug 27, 2006

Organization subpart

No

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

Authorized official

Name

Mr. Carl Robert Hendricks, R.PHNPI 1174651442

Title

Owner/R.PH.

Phone

(248) 669-2776

Specialties & licenses 4

Addresses

Other identifiers 4

Other names 1

• Pontiac Trail Medical Pharmacy Doing business as

Medicare fee-for-service enrollment

Enrolled in MI2 enrollments

Enrollment records 2

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

Medicare medical equipment & supply locations

Practitioners 2

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

• Carl Hendricks

  • Pharmacist
  • Walled Lake, MI
  • NPI 1174651442
  NPD Authorized official
• Karen Hendricks

  • Pharmacist
  • Walled Lake, MI
  • NPI 1386772648
  NPD

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

{
    "created_epoch": "1156636800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1501545600000",
    "number": "1902914377",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "43155 W. NINE MILE RD.",
            "city": "NOVI",
            "state": "MI",
            "postal_code": "483768026"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "620 N. PONTIAC TRAIL",
            "city": "WALLED LAKE",
            "state": "MI",
            "postal_code": "48390",
            "telephone_number": "248-669-2776",
            "fax_number": "248-669-2835"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PONTIAC TRAIL PHARMACY INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-27",
        "last_updated": "2017-08-01",
        "status": "A",
        "authorized_official_last_name": "HENDRICKS",
        "authorized_official_first_name": "CARL",
        "authorized_official_middle_name": "ROBERT",
        "authorized_official_title_or_position": "OWNER/R.PH.",
        "authorized_official_telephone_number": "248-669-2776",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "R.PH"
    },
    "taxonomies": [
        {
            "code": "261QH0100X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Health Service",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "MI",
            "license": "5301004197",
            "primary": true
        },
        {
            "code": "3336L0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Long Term Care Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2338689",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1665835",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1649484",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "OTHER ID NUMBER",
            "identifier": "2338689",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Pontiac Trail Medical Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Community/Retail Pharmacy in Walled Lake, MI
• Providers in Walled Lake, 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 Aug 1, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.