Provider Demographics
NPI:1114317393
Name:VILLAGE PHARMACY COMPOUNDING INC
Entity Type:Organization
Organization Name:VILLAGE PHARMACY COMPOUNDING INC
Other - Org Name:THE VILLAGE PHARMACY AND COMPOUNDING INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GABE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAWAIDEH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:248-644-6337
Mailing Address - Street 1:3592 WEST MAPLE RD.
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301
Mailing Address - Country:US
Mailing Address - Phone:248-644-6337
Mailing Address - Fax:248-644-1027
Practice Address - Street 1:3592 W MAPLE RD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48301-3371
Practice Address - Country:US
Practice Address - Phone:248-644-6337
Practice Address - Fax:248-644-1027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-27
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MI53010107283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1114317393Medicaid
2149862OtherPK