1932468303 NPI number — MED INDEX PHARMACY LLC

Table of content: (NPI 1932468303)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932468303 NPI number — MED INDEX PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MED INDEX PHARMACY 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:
Provider Other Organization Name Type Code:
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:
1932468303
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1639 E BIG BEAVER RD STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48083-2053
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-821-1260
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1639 E BIG BEAVER RD STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48083-2053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-528-0888
Provider Business Practice Location Address Fax Number:
248-526-0351
Provider Enumeration Date:
05/04/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GUNTUPALLI
Authorized Official First Name:
ANIL
Authorized Official Middle Name:
BABU
Authorized Official Title or Position:
PHARMACY MANAGER
Authorized Official Telephone Number:
248-821-1260

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 5301009808 , 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)