Provider Demographics
NPI:1962664060
Name:MADISON COMMUNITY HOSPITAL INC
Entity Type:Organization
Organization Name:MADISON COMMUNITY HOSPITAL INC
Other - Org Name:BC OF MICHIGAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNABALAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-792-1746
Mailing Address - Street 1:4050 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2534
Mailing Address - Country:US
Mailing Address - Phone:586-578-0220
Mailing Address - Fax:586-578-0225
Practice Address - Street 1:4050 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-2534
Practice Address - Country:US
Practice Address - Phone:586-578-0220
Practice Address - Fax:586-578-0225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010088443336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2807858Medicaid
2043722OtherPK