MEDICARE: GOSHEN PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	5301011832	OTHER	MI	PAHRMACY LICENSE

General Provider Information

NPI Number	:	1215570791
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOSHEN PHARMACY LLC

Provider Business Mailing Address
First Line	:	16800 GREENFIELD RD UNIT B2
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48235-3703
Country	:	US
Telephone Number	:	313-340-2882
Fax Number	:	313-340-2884

Provider Business Practice Location Address
First Line	:	16800 GREENFIELD RD UNIT B2
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48235-3703
Country	:	US
Telephone Number	:	248-385-2423
Fax Number	:

Authorized Official
Title or Position	:	PIC/MANAGER
Name	:	CHUKWUMA ABOMELI
Credential	:
Telephone Number	:	815-997-0380

Provider Enumeration Date	:	10/28/2019
Last Update Date	:	12/27/2019

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Directions to “GOSHEN PHARMACY LLC ” Practice Location

Language	Start Address	Practice Location

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