=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265687883
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAYNE COUNTY JAIL PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2008
-----------------------------------------------------
Last Update Date | 11/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 570 CLINTON ST JAIL MEDICAL
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48226-2334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-224-7912
-----------------------------------------------------
Fax | 313-224-0768
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 570 CLINTON ST JAIL MEDICAL
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48226-2334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-224-7912
-----------------------------------------------------
Fax | 313-224-0768
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY DIRECTOR
-----------------------------------------------------
Name | MR. JOHN CHARLES GAWRYK
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 313-224-7912
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2400X
-----------------------------------------------------
Taxonomy Name | Prison Health Clinic/Center
-----------------------------------------------------
License Number | 5301003163
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------