1902148356 NPI number — BUCKLEYS PHARMACY OF DETROIT LLC

Table of content: (NPI 1902148356)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902148356 NPI number — BUCKLEYS PHARMACY OF DETROIT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BUCKLEYS PHARMACY OF DETROIT 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:
BUCKLEY'S PHARMACY #103
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:
1902148356
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14313 GREENFIELD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48227-2107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-272-0202
Provider Business Mailing Address Fax Number:
313-272-0924

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14313 GREENFIELD RD
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:
48227-2107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-272-0202
Provider Business Practice Location Address Fax Number:
313-272-0924
Provider Enumeration Date:
03/25/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
COLE
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
313-971-5030

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 5301010055 , 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: 2377871 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".