Provider Demographics
NPI:1053355271
Name:ANDY'S MOTOWN PHARMACY
Entity type:Organization
Organization Name:ANDY'S MOTOWN PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ISMAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:JADALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-341-2450
Mailing Address - Street 1:14470 LIVERNOIS AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-2005
Mailing Address - Country:US
Mailing Address - Phone:313-341-2450
Mailing Address - Fax:
Practice Address - Street 1:14470 LIVERNOIS AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-2005
Practice Address - Country:US
Practice Address - Phone:313-341-2450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010084073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5712350001Medicare NSC