Provider Demographics
NPI:1306904032
Name:INDIAN VILLAGE PHARMACY
Entity type:Organization
Organization Name:INDIAN VILLAGE PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:AOUN
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:313-331-2000
Mailing Address - Street 1:8415 E JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214-2721
Mailing Address - Country:US
Mailing Address - Phone:313-331-2000
Mailing Address - Fax:313-331-2001
Practice Address - Street 1:8415 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-2721
Practice Address - Country:US
Practice Address - Phone:313-331-2000
Practice Address - Fax:313-331-2001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010077233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4548959Medicaid
2046489OtherPK
4934740001Medicare NSC