1275641631 NPI number — PINE KNOB PHARMACY 2 INC

Table of content: (NPI 1275641631)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275641631 NPI number — PINE KNOB PHARMACY 2 INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINE KNOB PHARMACY 2 INC
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:
Provider Other Organization Name Type Code:
6
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:
1275641631
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
43155 W 9 MILE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NOVI
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48375-4190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5625 WATER TOWER PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARKSTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48346-2671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-625-1215
Provider Business Practice Location Address Fax Number:
248-620-4258
Provider Enumeration Date:
08/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRAHAM
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER PHARMACY SERVICES
Authorized Official Telephone Number:
248-348-1570

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  5301006592 , 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: 2335380 . This is a "OTHER ID NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2335380 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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