1508996497 NPI number — PRAIRIESTONE PHARMACY LLC

Table of content: (NPI 1508996497)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508996497 NPI number — PRAIRIESTONE PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRAIRIESTONE 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:
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:
1508996497
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/25/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26777 CENTRAL PARK BLVD
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:
48076-4162
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-746-7779
Provider Business Mailing Address Fax Number:
763-746-7778

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4101 RAVENSWOOD RD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
FORT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33312-5373
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-797-7970
Provider Business Practice Location Address Fax Number:
954-797-7971
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HARMS
Authorized Official First Name:
KARI
Authorized Official Middle Name:
Authorized Official Title or Position:
THIRD PARTY ADMINISTRATOR
Authorized Official Telephone Number:
763-746-7764

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  PH22576 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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