Healthcare Provider Details

I. General information

NPI: 1801550843
Provider Name (Legal Business Name): USCG DETROIT PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2021
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43401 N JEFFERSON AVE BLDG 825
SELFRIDGE MI
48045-5266
US

IV. Provider business mailing address

43401 N JEFFERSON AVE BLDG 825
SELFRIDGE MI
48045-5266
US

V. Phone/Fax

Practice location:
  • Phone: 586-239-3005
  • Fax: 586-239-5010
Mailing address:
  • Phone: 586-239-3005
  • Fax: 586-239-5010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332000000X
TaxonomyMilitary/U.S. Coast Guard Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: HECTOR MORALES
Title or Position: CHIEF DHA PASS
Credential:
Phone: 210-536-6650