Provider Demographics
NPI:1316220155
Name:INTEGRATED DRUG MANAGEMENT
Entity Type:Organization
Organization Name:INTEGRATED DRUG MANAGEMENT
Other - Org Name:IDM PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FAUSTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:IROHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-943-1123
Mailing Address - Street 1:26541 PLYMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-2214
Mailing Address - Country:US
Mailing Address - Phone:313-543-3414
Mailing Address - Fax:313-543-3414
Practice Address - Street 1:26541 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-2214
Practice Address - Country:US
Practice Address - Phone:313-543-3414
Practice Address - Fax:313-543-3416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-27
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53150529083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2132642OtherPK
MI1316220155Medicaid
MI1316220155Medicaid