Provider Demographics
NPI:1295849214
Name:1616 FORD AVE DRUGS INC
Entity Type:Organization
Organization Name:1616 FORD AVE DRUGS INC
Other - Org Name:WYANDOTTE ACTION DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PETAR
Authorized Official - Middle Name:
Authorized Official - Last Name:DIMOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:734-285-3111
Mailing Address - Street 1:1616 FORD AVE
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-2304
Mailing Address - Country:US
Mailing Address - Phone:734-285-3111
Mailing Address - Fax:734-285-8258
Practice Address - Street 1:1616 FORD AVE
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-2304
Practice Address - Country:US
Practice Address - Phone:734-285-3111
Practice Address - Fax:734-285-8258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010065743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2356978Medicaid
MI2356978OtherNCPDP