1316290729 NPI number — DEARBORN FAMILY PHARMACY LLC

Table of content: (NPI 1316290729)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316290729 NPI number — DEARBORN FAMILY PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEARBORN FAMILY 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:
FAMILY PHARMACY LTC
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:
1316290729
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17000 EXECUTIVE PLAZA DR
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
DEARBORN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48126-2610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-982-3770
Provider Business Mailing Address Fax Number:
313-982-3771

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17000 EXECUTIVE PLAZA DR
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
DEARBORN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48126-2610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-982-3770
Provider Business Practice Location Address Fax Number:
313-982-3771
Provider Enumeration Date:
10/23/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ABUEIDA
Authorized Official First Name:
AIMAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
313-523-5334

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: 3336C0003X , with the licence number: 5301009879 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2377237 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".