Provider Demographics
NPI:1578684957
Name:DETR MED CTR HARPER HOSP
Entity Type:Organization
Organization Name:DETR MED CTR HARPER HOSP
Other - Org Name:DMC PAHRMACY HUTZEL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SYS EXEC DIR RETL PHRM
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-966-0392
Mailing Address - Street 1:PO BOX 673896
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-3896
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4727 SAINT ANTOINE ST
Practice Address - Street 2:STE 100A
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1461
Practice Address - Country:US
Practice Address - Phone:313-745-7444
Practice Address - Fax:313-745-7443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010085803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2369533OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MI2369533Medicaid