Provider Demographics
NPI:1043789431
Name:PHARMASOURCE LTC LLC
Entity Type:Organization
Organization Name:PHARMASOURCE LTC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:DR
Authorized Official - First Name:FADI
Authorized Official - Middle Name:
Authorized Official - Last Name:NASERDEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-261-4100
Mailing Address - Street 1:31620 GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48336-4234
Mailing Address - Country:US
Mailing Address - Phone:734-261-4100
Mailing Address - Fax:734-261-0404
Practice Address - Street 1:31620 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MI
Practice Address - Zip Code:48336-4234
Practice Address - Country:US
Practice Address - Phone:313-680-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-15
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy