Provider Demographics
NPI:1720421738
Name:CAREMERICA AT DETROIT LLC
Entity Type:Organization
Organization Name:CAREMERICA AT DETROIT LLC
Other - Org Name:CAREMERICA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:DYKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-750-1111
Mailing Address - Street 1:2255 FORT ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-2671
Mailing Address - Country:US
Mailing Address - Phone:313-357-7500
Mailing Address - Fax:313-357-7502
Practice Address - Street 1:2255 FORT ST
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2671
Practice Address - Country:US
Practice Address - Phone:313-357-7500
Practice Address - Fax:313-357-7502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-09
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010100763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139986OtherPK