Provider Demographics
NPI:1710073010
Name:ST JOSEPH MERCY PROFESSIONAL PHARMACY
Entity Type:Organization
Organization Name:ST JOSEPH MERCY PROFESSIONAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, PHARMACY SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:J
Authorized Official - Last Name:WEIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:248-858-3053
Mailing Address - Street 1:44405 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-5023
Mailing Address - Country:US
Mailing Address - Phone:248-858-3053
Mailing Address - Fax:248-858-3010
Practice Address - Street 1:44405 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5023
Practice Address - Country:US
Practice Address - Phone:248-452-5357
Practice Address - Fax:248-452-5292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010071393336C0003X, 3336H0001X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Not Answered3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2360876OtherNABP/NCPDP #
MI4168904Medicaid
MI4168922Medicaid
MI5301007139OtherMICHIGAN LICENSE #
MIBS6662111OtherDEA #
MIBS6662111OtherDEA #