Provider Demographics
NPI:1215990783
Name:CHILDRENS HOSPITAL OF MICHIGAN
Entity type:Organization
Organization Name:CHILDRENS HOSPITAL OF MICHIGAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR OF PHARMACY SERV
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BACH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:313-745-4151
Mailing Address - Street 1:3901 BEAUBIEN BLVD
Mailing Address - Street 2:ROOM 108
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2119
Mailing Address - Country:US
Mailing Address - Phone:313-745-1699
Mailing Address - Fax:313-745-1170
Practice Address - Street 1:3901 BEAUBIEN BLVD
Practice Address - Street 2:ROOM 108
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2119
Practice Address - Country:US
Practice Address - Phone:313-745-1699
Practice Address - Fax:313-745-1170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010078413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2365535Medicaid
MI2663690001Medicare ID - Type Unspecified