Provider Demographics
NPI:1093823460
Name:GREAT LAKES PHARMACIES I INC
Entity Type:Organization
Organization Name:GREAT LAKES PHARMACIES I INC
Other - Org Name:VILLAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:W
Authorized Official - Last Name:SIOMKA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:586-751-7979
Mailing Address - Street 1:6213 CHICAGO RD. SUITE 200
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092
Mailing Address - Country:US
Mailing Address - Phone:586-751-7979
Mailing Address - Fax:586-751-0809
Practice Address - Street 1:6213 CHICAGO RD SUITE 200
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092
Practice Address - Country:US
Practice Address - Phone:586-751-7979
Practice Address - Fax:586-751-0809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-27
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010041063336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1617121Medicaid
2338499OtherOTHER ID NUMBER
MI1617121Medicaid
2338499OtherOTHER ID NUMBER