MEDICARE: WEST BLOOMFIELD MARKET 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	5301009097	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2372489	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1306085394
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST BLOOMFIELD MARKET LLC

Provider Business Mailing Address
First Line	:	30777 NORTHWESTERN HWY
Second Line	:	STE 301
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48334-2549
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6565 ORCHARD LAKE RD
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322-3403
Country	:	US
Telephone Number	:	248-626-1111
Fax Number	:	248-626-1116

Authorized Official
Title or Position	:	VP OF PHARMACY
Name	:	JENNIFER MARTIN
Credential	:
Telephone Number	:	248-706-1600

Provider Enumeration Date	:	02/13/2009
Last Update Date	:	05/21/2009

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Directions to “WEST BLOOMFIELD MARKET LLC ” Practice Location

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