Provider Demographics
NPI:1114168176
Name:WARREN MEDICAL PHARMACY LLC
Entity Type:Organization
Organization Name:WARREN MEDICAL PHARMACY LLC
Other - Org Name:PHARMOR PHARMACY WARREN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WAGDI
Authorized Official - Middle Name:
Authorized Official - Last Name:ABDULLA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:586-757-9100
Mailing Address - Street 1:27379 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2844
Mailing Address - Country:US
Mailing Address - Phone:586-757-9100
Mailing Address - Fax:586-757-9122
Practice Address - Street 1:27379 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2844
Practice Address - Country:US
Practice Address - Phone:586-757-9100
Practice Address - Fax:586-757-9122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-20
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010090733336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1114168176Medicaid
2119509OtherPK