Provider Demographics
NPI:1023031002
Name:AMP PHARMACY SERVICES
Entity Type:Organization
Organization Name:AMP PHARMACY SERVICES
Other - Org Name:GREAT LAKES PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-729-5253
Mailing Address - Street 1:1629 S MERRIMAN RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48186-5301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1629 S MERRIMAN RD
Practice Address - Street 2:SUITE A
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186-5301
Practice Address - Country:US
Practice Address - Phone:734-729-5253
Practice Address - Fax:734-405-2306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301008307333600000X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2367995Medicaid
2367995OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MI2367995Medicaid