Provider Demographics
NPI:1265675037
Name:BLOOMFIELD PROFESSIONAL PHARMACY
Entity Type:Organization
Organization Name:BLOOMFIELD PROFESSIONAL PHARMACY
Other - Org Name:OAKLAND HILLS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GHANNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-756-5123
Mailing Address - Street 1:PO BOX 8039
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-8039
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2520 S TELEGRAPH RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0285
Practice Address - Country:US
Practice Address - Phone:248-758-9490
Practice Address - Fax:248-758-9502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-09
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010090903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2372629OtherNCPDP PROVIDER IDENTIFICATION NUMBER