Provider Demographics
NPI:1457787921
Name:GRACE MEDICAL PHARMACY LLC
Entity Type:Organization
Organization Name:GRACE MEDICAL PHARMACY LLC
Other - Org Name:GRACE MEDICAL PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MUYIWA JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SULE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-346-4480
Mailing Address - Street 1:20805 GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-3919
Mailing Address - Country:US
Mailing Address - Phone:313-255-2300
Mailing Address - Fax:313-255-2307
Practice Address - Street 1:20805 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-3919
Practice Address - Country:US
Practice Address - Phone:313-255-2300
Practice Address - Fax:313-255-2307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-17
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010101883336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2142091OtherPK
MI1457787921Medicaid