Provider Demographics
NPI:1356495709
Name:BEACON POINTE PHARMACY INC.
Entity Type:Organization
Organization Name:BEACON POINTE PHARMACY INC.
Other - Org Name:BEACON POINTE PHARMACY INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HASNA
Authorized Official - Middle Name:
Authorized Official - Last Name:IWAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:586-295-7221
Mailing Address - Street 1:15200 E JEFFERSON AVE
Mailing Address - Street 2:STE #102
Mailing Address - City:GROSSE POINTE PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1304
Mailing Address - Country:US
Mailing Address - Phone:313-822-5474
Mailing Address - Fax:313-822-8780
Practice Address - Street 1:15200 E JEFFERSON AVE
Practice Address - Street 2:STE #102
Practice Address - City:GROSSE POINTE PARK
Practice Address - State:MI
Practice Address - Zip Code:48230-1304
Practice Address - Country:US
Practice Address - Phone:313-822-5474
Practice Address - Fax:313-822-8780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
MI53010063883336C0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI33226861Medicaid
2040849OtherPK
MI3226861Medicaid