Provider Demographics
NPI:1922105287
Name:TRINITY HEALTH - MICHIGAN
Entity Type:Organization
Organization Name:TRINITY HEALTH - MICHIGAN
Other - Org Name:STJOSEPH MERCY PROFESSIONAL PHARMACY
Other - Org Type:Doing Business As
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:248-858-3059
Mailing Address - Fax:248-858-6031
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:248-858-3053
Practice Address - Fax:248-858-3010
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRINITY HEALTH - MICHIGAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010054823336C0003X
3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2347828OtherNABP/NCPDP#
MI5301005482OtherMICHIGAN LICENSE #
MI2693816Medicaid
MIBS2503224OtherDEA #
MI0628400002Medicare ID - Type Unspecified