Provider Demographics
NPI:1952704843
Name:STATE OF MICHIGAN
Entity Type:Organization
Organization Name:STATE OF MICHIGAN
Other - Org Name:D J JACOBETTI HOME FOR VETERANS
Other - Org Type:Other Name
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:G
Authorized Official - Last Name:HARVALA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:906-226-3576
Mailing Address - Street 1:425 FISHER ST
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4521
Mailing Address - Country:US
Mailing Address - Phone:906-226-3576
Mailing Address - Fax:906-226-3507
Practice Address - Street 1:425 FISHER ST
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4521
Practice Address - Country:US
Practice Address - Phone:906-226-3576
Practice Address - Fax:906-226-3507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-06
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302027451333600000X, 3336I0012X
MI53010056043336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI002286Medicaid