1366044018 NPI number — ABES DRUG STORE 102 LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366044018 NPI number — ABES DRUG STORE 102 LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ABES DRUG STORE 102 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:
ABE'S DRUG STORE
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:
1366044018
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13770 E 12 MILE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARREN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48088-3751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-459-0836
Provider Business Mailing Address Fax Number:
586-571-0650

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30695 LITTLE MACK AVE STE F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48066-1771
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-459-0836
Provider Business Practice Location Address Fax Number:
586-571-0650
Provider Enumeration Date:
11/09/2020

Additional Information

Authorized Official

Authorized Official Last Name:
KASSEM
Authorized Official First Name:
RAMZI
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
313-377-6623

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5301013171 . This is a "PHARMACY LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5315242183 . This is a "PHARMACY CONTROLLED SUBSTANCE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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