Provider Demographics
NPI:1013345024
Name:HENRY FORD ALLEGIANCE PHARMACY
Entity Type:Organization
Organization Name:HENRY FORD ALLEGIANCE PHARMACY
Other - Org Name:HENRY FORD ALLEGIANCE PHARMACY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SVP-OPS/CONTIN OF CARE
Authorized Official - Prefix:
Authorized Official - First Name:ONDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:BATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-205-7201
Mailing Address - Street 1:205 N EAST AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1753
Mailing Address - Country:US
Mailing Address - Phone:517-205-4907
Mailing Address - Fax:517-205-5947
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-205-4907
Practice Address - Fax:517-205-5947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-30
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010101593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2142662OtherPK
MIMI6500OtherPTAN
MI0773750004Medicare NSC