Provider Demographics
NPI:1508103292
Name:BSW PHARMACY SERVICES LLC
Entity Type:Organization
Organization Name:BSW PHARMACY SERVICES LLC
Other - Org Name:WAYNE PROFESSIONAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:DOMINICK
Authorized Official - Middle Name:
Authorized Official - Last Name:RUTHERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-728-8306
Mailing Address - Street 1:34841 VETERANS PLZ
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-1733
Mailing Address - Country:US
Mailing Address - Phone:734-728-8306
Mailing Address - Fax:734-728-8506
Practice Address - Street 1:34841 VETERANS PLZ
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-1733
Practice Address - Country:US
Practice Address - Phone:734-728-8306
Practice Address - Fax:734-728-8506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-15
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010099953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2138536OtherPK