Provider Demographics
NPI:1508909847
Name:ST JOSEPH MERCY PROFESSIONAL PHARMACY
Entity Type:Organization
Organization Name:ST JOSEPH MERCY PROFESSIONAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PHIL
Authorized Official - Middle Name:
Authorized Official - Last Name:WEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-858-3053
Mailing Address - Street 1:PO BOX 3470
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48333-3470
Mailing Address - Country:US
Mailing Address - Phone:248-305-7985
Mailing Address - Fax:248-305-8677
Practice Address - Street 1:44405 WOODWARD AVE
Practice Address - Street 2:B116
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5023
Practice Address - Country:US
Practice Address - Phone:248-305-7985
Practice Address - Fax:248-305-8677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4168922Medicaid
MIOF300520OtherBCBS HIT
MIOF316770OtherBCBS DME
MIOF316770OtherBCBS DME