Provider Demographics
NPI:1073747127
Name:REDFORD DISCOUNT PHARMACY PLLC
Entity Type:Organization
Organization Name:REDFORD DISCOUNT PHARMACY PLLC
Other - Org Name:REDFORD DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:IKENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DURU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-533-7920
Mailing Address - Street 1:25850 GRAND RIVER
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25850 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48240-1433
Practice Address - Country:US
Practice Address - Phone:313-533-7920
Practice Address - Fax:313-533-7923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-05
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010090913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2372732OtherNCPDP PROVIDER IDENTIFICATION NUMBER