Provider Demographics
NPI:1043629488
Name:JAY SHRI GANESH INC
Entity type:Organization
Organization Name:JAY SHRI GANESH INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MINAXI
Authorized Official - Middle Name:
Authorized Official - Last Name:BIDJA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-554-2745
Mailing Address - Street 1:42086 GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1643
Mailing Address - Country:US
Mailing Address - Phone:586-554-2745
Mailing Address - Fax:586-554-2746
Practice Address - Street 1:42086 GARFIELD RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038
Practice Address - Country:US
Practice Address - Phone:586-554-2745
Practice Address - Fax:586-554-2746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-11
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
MI53010105963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacyGroup - Single Specialty
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1043629488Medicaid
2148637OtherPK