Provider Demographics
NPI:1295032449
Name:DOWNRIVER COMMUNITY SERVICES INC
Entity Type:Organization
Organization Name:DOWNRIVER COMMUNITY SERVICES INC
Other - Org Name:DCS PHARMACY - NEW HAVEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-339-1075
Mailing Address - Street 1:58144 GRATIOT AVE
Mailing Address - Street 2:PO BOX 480430
Mailing Address - City:NEW HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:48048
Mailing Address - Country:US
Mailing Address - Phone:586-270-8055
Mailing Address - Fax:586-270-8064
Practice Address - Street 1:58144 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:MI
Practice Address - Zip Code:48048
Practice Address - Country:US
Practice Address - Phone:586-339-1075
Practice Address - Fax:586-339-1071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-24
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010095013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1679571392Medicaid
2375144OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MI1679571392Medicaid