Provider Demographics
NPI:1417133307
Name:CHILDRENS HOSPITAL OF MICHIGAN
Entity Type:Organization
Organization Name:CHILDRENS HOSPITAL OF MICHIGAN
Other - Org Name:DMC PHARMACY STILSON CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-966-0392
Mailing Address - Street 1:PO BOX 674032
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-4032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:42700 GARFIELD RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-4201
Practice Address - Country:US
Practice Address - Phone:586-532-2980
Practice Address - Fax:586-416-1432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010087613336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2370649OtherNCPDP PROVIDER IDENTIFICATION NUMBER