=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700872678
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BON SECOURS PHARMACY AND HEALTH SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21571 KELLY RD
-----------------------------------------------------
City | EASTPOINTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48021-3213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-774-0880
-----------------------------------------------------
Fax | 586-774-1075
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21400 E 11 MILE RD
-----------------------------------------------------
City | ST CLAIR SHORES
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48081-1502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-498-4470
-----------------------------------------------------
Fax | 586-772-6320
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | KENNETH S WOODS
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 586-498-4470
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 5301004696
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------