1508909847 NPI number — ST JOSEPH MERCY PROFESSIONAL PHARMACY

Table of content: (NPI 1508909847)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508909847 NPI number — ST JOSEPH MERCY PROFESSIONAL PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST JOSEPH MERCY PROFESSIONAL PHARMACY
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:
Provider Other Organization Name Type Code:
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:
1508909847
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3470
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48333-3470
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-305-7985
Provider Business Mailing Address Fax Number:
248-305-8677

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44405 WOODWARD AVE
Provider Second Line Business Practice Location Address:
B116
Provider Business Practice Location Address City Name:
PONTIAC
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48341-5023
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-305-7985
Provider Business Practice Location Address Fax Number:
248-305-8677
Provider Enumeration Date:
02/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WEIN
Authorized Official First Name:
PHIL
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY MANAGER
Authorized Official Telephone Number:
248-858-3053

Provider Taxonomy Codes

  • Taxonomy code: 3336H0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4168922 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: OF300520 . This is a "BCBS HIT" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: OF316770 . This is a "BCBS DME" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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