1417133430 NPI number — ORCHARD VIEW PHARMACY LLC

Table of content: STACEY JESSER (NPI 1326454166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417133430 NPI number — ORCHARD VIEW PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORCHARD VIEW 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:
ORCHARD VIEW PHARMACY LLC
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:
1417133430
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12150 30 MILE RD STE 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTON TWP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48095
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-336-9552
Provider Business Mailing Address Fax Number:
586-336-9583

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12150 30 MILE RD STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON TWP
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48095
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-336-9552
Provider Business Practice Location Address Fax Number:
586-336-9583
Provider Enumeration Date:
01/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SAYWRAYNE
Authorized Official First Name:
PHILIP
Authorized Official Middle Name:
V.
Authorized Official Title or Position:
MEMBER/OWNER
Authorized Official Telephone Number:
313-510-3313

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  5301008784 , 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: 2043576 . This is a "PK" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com