Provider Demographics
NPI:1033125679
Name:MACOMB PHARMACY, INC.
Entity Type:Organization
Organization Name:MACOMB PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GHANNAM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:586-979-9020
Mailing Address - Street 1:2405 E 14 MILE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-5961
Mailing Address - Country:US
Mailing Address - Phone:586-979-9020
Mailing Address - Fax:586-979-9032
Practice Address - Street 1:2405 E 14 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-5961
Practice Address - Country:US
Practice Address - Phone:586-979-9020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010081723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5504190001Medicare ID - Type UnspecifiedMEDICARE ID NUMBER