Provider Demographics
NPI:1518953488
Name:BEAUMONT PHARMACY AND HEALTH SERVICES INC
Entity Type:Organization
Organization Name:BEAUMONT PHARMACY AND HEALTH SERVICES INC
Other - Org Name:BEAUMONT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:S
Authorized Official - Last Name:WOODS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:586-498-4470
Mailing Address - Street 1:21400 E 11 MILE RD
Mailing Address - Street 2:
Mailing Address - City:ST CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1502
Mailing Address - Country:US
Mailing Address - Phone:586-498-4470
Mailing Address - Fax:586-772-6320
Practice Address - Street 1:21400 E 11 MILE RD
Practice Address - Street 2:
Practice Address - City:ST CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1502
Practice Address - Country:US
Practice Address - Phone:586-498-4470
Practice Address - Fax:586-772-6320
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLIAM BEAUMONT HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-26
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010087223336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1622927Medicaid