Provider Demographics
NPI:1083757140
Name:RICHARDSON MEDICAL PHARMACY, INC.
Entity Type:Organization
Organization Name:RICHARDSON MEDICAL PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:WAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KHANAFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-412-4622
Mailing Address - Street 1:29800 SOUTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2037
Mailing Address - Country:US
Mailing Address - Phone:248-557-6900
Mailing Address - Fax:248-557-6901
Practice Address - Street 1:29800 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2037
Practice Address - Country:US
Practice Address - Phone:248-557-6900
Practice Address - Fax:248-557-6901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010083413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2366967OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MI2366967Medicaid
MI2366967Medicare PIN