Provider Demographics
NPI:1669865838
Name:EAST JORDAN FAMILY HEALTH CENTER
Entity Type:Organization
Organization Name:EAST JORDAN FAMILY HEALTH CENTER
Other - Org Name:BELLAIRE FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-536-2206
Mailing Address - Street 1:601 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:EAST JORDAN
Mailing Address - State:MI
Mailing Address - Zip Code:49727-9383
Mailing Address - Country:US
Mailing Address - Phone:231-536-2206
Mailing Address - Fax:231-536-7739
Practice Address - Street 1:4955 S M 88 HWY
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:MI
Practice Address - Zip Code:49615-9082
Practice Address - Country:US
Practice Address - Phone:231-533-6655
Practice Address - Fax:231-533-5331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-12
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010106663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1669865838Medicaid
2149742OtherPK