1366954067 NPI number — E DAVIDSON RX LLC

Table of content: (NPI 1366954067)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366954067 NPI number — E DAVIDSON RX LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
E DAVIDSON RX 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:
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:
1366954067
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6689 ORCHARD LAKE RD STE 168
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST BLOOMFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48322-3404
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:
4420 E DAVISON ST
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:
48212-1744
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-334-6711
Provider Business Practice Location Address Fax Number:
313-334-6710
Provider Enumeration Date:
11/02/2017

Additional Information

Authorized Official

Authorized Official Last Name:
TOLF
Authorized Official First Name:
CANDICE
Authorized Official Middle Name:
Authorized Official Title or Position:
3RD PARTY COORDINATOR
Authorized Official Telephone Number:
313-751-7979

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  5301010812 , 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: FSRX1950290 . This is a "FLEXSCRIPT" identifier . This identifiers is of the category "OTHER".




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