Provider Demographics
NPI:1720196199
Name:FAIRWAY DRUGS INC
Entity Type:Organization
Organization Name:FAIRWAY DRUGS INC
Other - Org Name:FAIRWAY DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLAGHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-348-1570
Mailing Address - Street 1:43155 W 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-4190
Mailing Address - Country:US
Mailing Address - Phone:248-348-1470
Mailing Address - Fax:248-348-4316
Practice Address - Street 1:19332 E 10 MILE RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-1450
Practice Address - Country:US
Practice Address - Phone:586-771-0030
Practice Address - Fax:586-771-2169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-27
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010049653336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2344163OtherOTHER ID NUMBER
MIOP51190OtherMASS IMMUNIZATION ROSTER BILLER
MI2344163Medicaid
MIMI6999OtherPHARMACY/DIABETES SELF-MANAGEMENT EDUCATION
0572410001Medicare NSC