1003924465 NPI number — WALNUT ASSOCIATES I LLC

Table of content: (NPI 1003924465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003924465 NPI number — WALNUT ASSOCIATES I LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALNUT ASSOCIATES I LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WEST GRANGE PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003924465
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/18/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3390 WEST ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRENTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48183-2323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-676-6622
Provider Business Mailing Address Fax Number:
734-676-5725

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3390 WEST ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRENTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48183
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-676-6622
Provider Business Practice Location Address Fax Number:
734-676-5725
Provider Enumeration Date:
08/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NEWMAN
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
248-354-0282

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  5301006407 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2308054 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2308054 . This is a "OTHER ID NUMBER" identifier . This identifiers is of the category "OTHER".