Provider Demographics
NPI:1558429670
Name:HENRY FORD WYANDOTTE HOSPITAL
Entity Type:Organization
Organization Name:HENRY FORD WYANDOTTE HOSPITAL
Other - Org Name:HFWH OUTPATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KUS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:248-723-0255
Mailing Address - Street 1:2333 BIDDLE AVE
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-4668
Mailing Address - Country:US
Mailing Address - Phone:734-246-9499
Mailing Address - Fax:734-246-6961
Practice Address - Street 1:2333 BIDDLE AVE
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-4668
Practice Address - Country:US
Practice Address - Phone:734-246-9499
Practice Address - Fax:734-246-6961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010047883336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2357374Medicaid
2044000OtherPK