1891803268 NPI number — PINE KNOB PHARMACY #3, INC.

Table of content: (NPI 1891803268)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891803268 NPI number — PINE KNOB PHARMACY #3, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINE KNOB PHARMACY #3, 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:
SAV-MOR #38 PINE KNOB #3
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:
1891803268
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6770 DIXIE HIGHWAY
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
CLARKSTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48346
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-620-3588
Provider Business Mailing Address Fax Number:
248-620-0037

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6770 DIXIE HIGHWAY
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
CLARKSTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48346
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-620-3588
Provider Business Practice Location Address Fax Number:
248-620-0037
Provider Enumeration Date:
08/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BULLARD
Authorized Official First Name:
RAY
Authorized Official Middle Name:
ALEXANDER
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-620-3588

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  5301006232 , 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: 2354126 . This is a "OTHER ID NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2354126 . This is a "NABP/NCPDP" identifier . This identifiers is of the category "OTHER".




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