Provider Demographics
NPI:1154681054
Name:GOG PHARMACY PLLC
Entity type:Organization
Organization Name:GOG PHARMACY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, PIC
Authorized Official - Prefix:
Authorized Official - First Name:FAUSTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:IROHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-943-1123
Mailing Address - Street 1:30917 WESTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-1466
Mailing Address - Country:US
Mailing Address - Phone:248-943-1123
Mailing Address - Fax:248-595-8299
Practice Address - Street 1:3600 OAKWOOD BLVD
Practice Address - Street 2:
Practice Address - City:MELVINDALE
Practice Address - State:MI
Practice Address - Zip Code:48122-1150
Practice Address - Country:US
Practice Address - Phone:313-382-3996
Practice Address - Fax:313-382-3989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-24
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010098293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2135464OtherPK
MI1154681054Medicaid