Provider Demographics
NPI:1679737480
Name:DETROIT COMMUNITY HEALTH CONNECTION
Entity Type:Organization
Organization Name:DETROIT COMMUNITY HEALTH CONNECTION
Other - Org Name:DETROIT COMMUNITY HEALTH CONNECTION PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:W
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:313-343-2891
Mailing Address - Street 1:7900 KERCHEVAL STREET
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214
Mailing Address - Country:US
Mailing Address - Phone:313-924-9798
Mailing Address - Fax:313-924-6244
Practice Address - Street 1:7900 KERCHEVAL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-2439
Practice Address - Country:US
Practice Address - Phone:313-924-9798
Practice Address - Fax:313-924-6244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-11
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010088963336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1679737480Medicaid
2116456OtherPK