Provider Demographics
NPI:1215037544
Name:THE PHARM OF MICHIGAN
Entity Type:Organization
Organization Name:THE PHARM OF MICHIGAN
Other - Org Name:PHARM PHARMACY 6102
Other - Org Type:Doing Business As
Authorized Official - Title/Position:THIRD PARTY CONTRACT ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:BSPS
Authorized Official - Phone:419-891-4991
Mailing Address - Street 1:124 E FRONT ST
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-2710
Mailing Address - Country:US
Mailing Address - Phone:517-265-2101
Mailing Address - Fax:517-263-6074
Practice Address - Street 1:124 E FRONT ST
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-2710
Practice Address - Country:US
Practice Address - Phone:517-265-2101
Practice Address - Fax:517-263-6074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301007193333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI01926727Medicaid
2343969OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MI1215037544OtherNPI
MI2343969OtherNCPDP
MI4821951OtherMEDICAID-DME
MI01926727Medicaid