Provider Demographics
NPI:1932268034
Name:DETROIT PHARMACY
Entity Type:Organization
Organization Name:DETROIT PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHCST
Authorized Official - Prefix:MR
Authorized Official - First Name:IBRAHIM
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHAMI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:734-262-4600
Mailing Address - Street 1:PO BOX 530815
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48153-0815
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18925 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-2273
Practice Address - Country:US
Practice Address - Phone:313-272-1400
Practice Address - Fax:313-272-3816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MI53010079423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2366107OtherOTHER ID NUMBER-COMMERCIAL NUMBER
2366107OtherOTHER ID NUMBER
MI2366107Medicaid
5186370001Medicare NSC