Provider Demographics
NPI:1275676066
Name:TRINITY HEALTH MICHIGAN
Entity Type:Organization
Organization Name:TRINITY HEALTH MICHIGAN
Other - Org Name:TRINITY HEALTH PHARMACY - DETROIT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TAWANA
Authorized Official - Middle Name:MIDDLE
Authorized Official - Last Name:NETTLES-ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-692-8400
Mailing Address - Street 1:5555 CONNER ST
Mailing Address - Street 2:SUITE 2691
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213-3448
Mailing Address - Country:US
Mailing Address - Phone:313-579-4004
Mailing Address - Fax:313-267-0057
Practice Address - Street 1:5555 CONNER ST STE 2691
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-3812
Practice Address - Country:US
Practice Address - Phone:313-692-8400
Practice Address - Fax:313-692-8437
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRINITY HEALTH MICHIGAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-14
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5301007421OtherSTATE LICENSE