Provider Demographics
NPI:1366501504
Name:OM SHRI CORPORATION
Entity Type:Organization
Organization Name:OM SHRI CORPORATION
Other - Org Name:BRYANS CORNER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:NUTAN
Authorized Official - Middle Name:MOTICHAND
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:810-793-5006
Mailing Address - Street 1:6002 N LAPEER RD
Mailing Address - Street 2:
Mailing Address - City:NORTH BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48461-9730
Mailing Address - Country:US
Mailing Address - Phone:810-793-5006
Mailing Address - Fax:810-793-5101
Practice Address - Street 1:6002 N LAPEER RD
Practice Address - Street 2:
Practice Address - City:NORTH BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48461-9730
Practice Address - Country:US
Practice Address - Phone:810-793-5006
Practice Address - Fax:810-793-5101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301007648333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2356156Medicaid
2356156OtherNABP#
2356156OtherNABP#