Provider Demographics
NPI:1871539320
Name:COUNTRYSIDE DRUG COMPANY I
Entity type:Organization
Organization Name:COUNTRYSIDE DRUG COMPANY I
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STRATTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-831-4140
Mailing Address - Street 1:PO BOX 727
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48888-0727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:217 E MAIN ST
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:MI
Practice Address - Zip Code:48888-9806
Practice Address - Country:US
Practice Address - Phone:989-831-4140
Practice Address - Fax:989-831-5801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010044223336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2039498OtherPK
MI1756250Medicaid