Basic Information
| Provider Information | |||||||||
| NPI: | 1124040035 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OAKWOOD PHARMACY LINCOLN PARK | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OAKWOOD HEALTHCARE INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26901 BEAUMONT BLVD. | ||||||||
| Address2: | COMPLIANCE | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480334716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9475221963 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 25650 W OUTER DRIVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LINCOLN PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481462096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132941520 | ||||||||
| FaxNumber: | 3132941525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 10/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | ODOM | ||||||||
| AuthorizedOfficialFirstName: | LEE | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT SHARED SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 9475223326 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 5301006701 | MI | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 3428689 | 05 | MI | MEDICAID |