Provider Demographics
NPI:1457387185
Name:GPS OF MICHIGAN INSTITUTIONAL
Entity Type:Organization
Organization Name:GPS OF MICHIGAN INSTITUTIONAL
Other - Org Name:GPS OF MICHIGAN INSTITUTIONAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:GHANNAM
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:517-882-5515
Mailing Address - Street 1:1201 KEYSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-4041
Mailing Address - Country:US
Mailing Address - Phone:517-882-5515
Mailing Address - Fax:517-882-6313
Practice Address - Street 1:1201 KEYSTONE AVE
Practice Address - Street 2:STE A
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-4041
Practice Address - Country:US
Practice Address - Phone:517-882-5515
Practice Address - Fax:517-882-6313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336I0012X
MI53010077203336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2364937Medicaid
MI0097325145Medicaid
2364937OtherNCPDP PROVIDER IDENTIFICATION NUMBER
5582260001Medicare NSC