Provider Demographics
NPI:1215570791
Name:GOSHEN PHARMACY LLC
Entity Type:Organization
Organization Name:GOSHEN PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHUKWUMA
Authorized Official - Middle Name:
Authorized Official - Last Name:ABOMELI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-997-0380
Mailing Address - Street 1:16800 GREENFIELD RD UNIT B2
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-3703
Mailing Address - Country:US
Mailing Address - Phone:313-340-2882
Mailing Address - Fax:313-340-2884
Practice Address - Street 1:16800 GREENFIELD RD UNIT B2
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3703
Practice Address - Country:US
Practice Address - Phone:248-385-2423
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-28
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1215570791Medicaid
MI5301011832OtherPAHRMACY LICENSE