Provider Demographics
NPI:1568449627
Name:MONROE STREET PHARMACY
Entity Type:Organization
Organization Name:MONROE STREET PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMOOD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:313-274-9141
Mailing Address - Street 1:2305 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3009
Mailing Address - Country:US
Mailing Address - Phone:313-274-9141
Mailing Address - Fax:313-274-9182
Practice Address - Street 1:2305 MONROE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3009
Practice Address - Country:US
Practice Address - Phone:313-274-9141
Practice Address - Fax:313-274-9182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301006022183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2352691Medicaid
MI2352691Medicaid