1720590425 NPI number — HIGHLAND PARK RX LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720590425 NPI number — HIGHLAND PARK RX LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HIGHLAND PARK 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:
1720590425
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:
13821 WOODWARD AVE STE B
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:
48203-3624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-334-6722
Provider Business Practice Location Address Fax Number:
313-334-6720
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:  5301010815 , 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: FSRX8346512 . This is a "FLEXSCRIPT" identifier . This identifiers is of the category "OTHER".




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