Provider Demographics
NPI:1750347340
Name:GPS OF MICHIGAN LLC
Entity type:Organization
Organization Name:GPS OF MICHIGAN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:GHANNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-232-9270
Mailing Address - Street 1:1201 FLUSHING RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48504-4730
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 FLUSHING RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48504-4730
Practice Address - Country:US
Practice Address - Phone:810-232-1351
Practice Address - Fax:810-232-9270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301007108333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4156144Medicaid
2349593OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MIBT6598378OtherDEA #