Provider Demographics
NPI:1457425977
Name:DETROIT MEDICAL PHARMACY INC
Entity Type:Organization
Organization Name:DETROIT MEDICAL PHARMACY INC
Other - Org Name:DETROIT MEDICAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PIC
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:
Authorized Official - Last Name:SOHOUBAH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:313-831-2400
Mailing Address - Street 1:500 E WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-1436
Mailing Address - Country:US
Mailing Address - Phone:313-831-2400
Mailing Address - Fax:313-831-2445
Practice Address - Street 1:500 E WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1436
Practice Address - Country:US
Practice Address - Phone:313-831-2400
Practice Address - Fax:313-831-2445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336S0011X
MI53010077483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2365220Medicaid
2046547OtherPK
MI2365220Medicaid