Provider Demographics
NPI:1043584725
Name:PIONEER MEDICAL PHARMACY LLC
Entity Type:Organization
Organization Name:PIONEER MEDICAL PHARMACY LLC
Other - Org Name:PIONEER MEDICAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHITTIPROLU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-635-8827
Mailing Address - Street 1:12701 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-6847
Mailing Address - Country:US
Mailing Address - Phone:734-250-8858
Mailing Address - Fax:734-250-8901
Practice Address - Street 1:12701 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-6847
Practice Address - Country:US
Practice Address - Phone:734-250-8858
Practice Address - Fax:734-250-8901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-28
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336S0011X
MI53010097563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2376398OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MI6688280001Medicare NSC