1831441971 NPI number — PREMIER HOME PHARMACY OF MI

Table of content: (NPI 1831441971)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831441971 NPI number — PREMIER HOME PHARMACY OF MI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER HOME PHARMACY OF MI
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:
PREMIER HOME PHARMACY OF MI
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:
1831441971
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23874 KEAN ST
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
DEARBORN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48124-1804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-887-9111
Provider Business Mailing Address Fax Number:
313-887-4229

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23874 KEAN ST
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
DEARBORN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48124-1804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-887-9111
Provider Business Practice Location Address Fax Number:
313-887-4229
Provider Enumeration Date:
10/13/2012

Additional Information

Authorized Official

Authorized Official Last Name:
RAZA
Authorized Official First Name:
SYED
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
734-658-8985

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: 5301010075 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1831441971 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2137422 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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