Provider Demographics
NPI:1730471194
Name:MEDEX HEALTH MART
Entity Type:Organization
Organization Name:MEDEX HEALTH MART
Other - Org Name:MEDEX HEALTH MART
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:IMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHAMMAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-397-2054
Mailing Address - Street 1:13970 WYOMING ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-2334
Mailing Address - Country:US
Mailing Address - Phone:313-397-2054
Mailing Address - Fax:313-397-2160
Practice Address - Street 1:13970 WYOMING ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-2334
Practice Address - Country:US
Practice Address - Phone:313-397-2054
Practice Address - Fax:313-397-2160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-04
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010095543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2375550OtherNCPDP PROVIDER IDENTIFICATION NUMBER