Provider Demographics
NPI:1730290750
Name:COVENANT MEDICAL CENTER INC
Entity Type:Organization
Organization Name:COVENANT MEDICAL CENTER INC
Other - Org Name:COVENANT HEALTHCARE OUTPATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:TERRENCE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WERNETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-583-4075
Mailing Address - Street 1:700 COOPER AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-5383
Mailing Address - Country:US
Mailing Address - Phone:989-583-6484
Mailing Address - Fax:
Practice Address - Street 1:700 COOPER AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-5383
Practice Address - Country:US
Practice Address - Phone:989-583-6484
Practice Address - Fax:989-583-6351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010052823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4104630Medicaid
MI4104630Medicaid