1215037544 NPI number — THE PHARM OF MICHIGAN

Table of content: (NPI 1215037544)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215037544 NPI number — THE PHARM OF MICHIGAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE PHARM OF MICHIGAN
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PHARM PHARMACY 6102
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215037544
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
124 E FRONT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ADRIAN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49221-2710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-265-2101
Provider Business Mailing Address Fax Number:
517-263-6074

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 E FRONT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ADRIAN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49221-2710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-265-2101
Provider Business Practice Location Address Fax Number:
517-263-6074
Provider Enumeration Date:
09/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
THIRD PARTY CONTRACT ADMIN
Authorized Official Telephone Number:
419-891-4991

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  5301007193 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01926727 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2343969 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1215037544 . This is a "NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2343969 . This is a "NCPDP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4821951 . This is a "MEDICAID-DME" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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