1376846980 NPI number — SAV-MART PHARMACY-GRATIOT LLC

Table of content: (NPI 1376846980)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376846980 NPI number — SAV-MART PHARMACY-GRATIOT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAV-MART PHARMACY-GRATIOT 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:
SAV-MART PHARMACY II
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:
1376846980
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23815 NORTHWESTERN HWY
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48075-7738
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-663-3380
Provider Business Mailing Address Fax Number:
248-223-1061

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7011 GRATIOT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48207-1973
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-923-0007
Provider Business Practice Location Address Fax Number:
313-923-0098
Provider Enumeration Date:
12/21/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SHOUBAH
Authorized Official First Name:
ABDO
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
313-923-0007

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 5301009409 , 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: 2127796 . This is a "PK" identifier . This identifiers is of the category "OTHER".