Healthcare Provider Details

I. General information

NPI: 1942254321
Provider Name (Legal Business Name): STATE OF MICHIGAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 05/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8303 PLATT RD
SALINE MI
48176-9773
US

IV. Provider business mailing address

8303 PLATT RD
SALINE MI
48176-9773
US

V. Phone/Fax

Practice location:
  • Phone: 734-295-4590
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License NumberA154961
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM PITTMAN
Title or Position: REIMBURSEMENT OFFICE
Credential:
Phone: 734-295-4590