Provider Demographics
NPI:1982861514
Name:PREFERRED SPECIALTY PHARMACY AND HOME INFUSION
Entity Type:Organization
Organization Name:PREFERRED SPECIALTY PHARMACY AND HOME INFUSION
Other - Org Name:PREFERRED SPECIALTY PHARMACY AND HOME INFUSION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-864-9000
Mailing Address - Street 1:16633 LIVERNOIS AVE
Mailing Address - Street 2:STE 3
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-3098
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16633 LIVERNOIS AVE
Practice Address - Street 2:STE 3
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-3098
Practice Address - Country:US
Practice Address - Phone:313-864-9000
Practice Address - Fax:313-864-9005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336C0004X, 3336H0001X
MI11882193336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2371209OtherOTHER ID NUMBER