Provider Demographics
NPI:1568487122
Name:BORMANS INC
Entity Type:Organization
Organization Name:BORMANS INC
Other - Org Name:FARMER JACK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIJOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-571-8326
Mailing Address - Street 1:23101 JOHN R RD
Mailing Address - Street 2:
Mailing Address - City:HAZEL PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48030-1475
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23101 JOHN R RD
Practice Address - Street 2:
Practice Address - City:HAZEL PARK
Practice Address - State:MI
Practice Address - Zip Code:48030-1475
Practice Address - Country:US
Practice Address - Phone:248-399-5208
Practice Address - Fax:248-399-4375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301005870333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2351360OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MI2930035Medicaid