Provider Demographics
NPI:1003273202
Name:DIVINE PHARMACY LLC
Entity Type:Organization
Organization Name:DIVINE PHARMACY LLC
Other - Org Name:DIVINE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REMY
Authorized Official - Middle Name:
Authorized Official - Last Name:ONIMOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-657-1727
Mailing Address - Street 1:16191 LIVERNOIS AVENUE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-3724
Mailing Address - Country:US
Mailing Address - Phone:313-651-9059
Mailing Address - Fax:313-659-6965
Practice Address - Street 1:16191 LIVERNOIS AVENUE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221
Practice Address - Country:US
Practice Address - Phone:313-651-9059
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-20
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010107943336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2157415OtherPK
MI1003273202Medicaid