Provider Demographics
NPI:1003295569
Name:MI CARE PHARMACY LLC
Entity Type:Organization
Organization Name:MI CARE PHARMACY LLC
Other - Org Name:MI CARE PHARMACY II
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER,AO
Authorized Official - Prefix:
Authorized Official - First Name:RENU
Authorized Official - Middle Name:
Authorized Official - Last Name:PATHAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-783-5539
Mailing Address - Street 1:33 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2331
Mailing Address - Country:US
Mailing Address - Phone:586-447-8777
Mailing Address - Fax:586-447-8902
Practice Address - Street 1:33 CHURCH ST
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2331
Practice Address - Country:US
Practice Address - Phone:586-447-8777
Practice Address - Fax:586-447-8902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-29
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010106813336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2152207OtherPK