Provider Demographics
NPI:1033726807
Name:PORTLAND PHARMACY INC
Entity Type:Organization
Organization Name:PORTLAND PHARMACY INC
Other - Org Name:PORTLAND PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MALIK
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAIBI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:313-442-2400
Mailing Address - Street 1:1295 PORTLAND AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-2726
Mailing Address - Country:US
Mailing Address - Phone:585-537-7081
Mailing Address - Fax:585-568-7909
Practice Address - Street 1:1295 PORTLAND AVE STE 2
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-2726
Practice Address - Country:US
Practice Address - Phone:585-537-7081
Practice Address - Fax:585-568-7909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-25
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy