Provider Demographics
NPI:1134473713
Name:NORTHVILLE PHARMACY LLC
Entity Type:Organization
Organization Name:NORTHVILLE PHARMACY LLC
Other - Org Name:NORTHVILLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:LINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-522-7519
Mailing Address - Street 1:116 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-1521
Mailing Address - Country:US
Mailing Address - Phone:248-924-3752
Mailing Address - Fax:248-924-3760
Practice Address - Street 1:116 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1521
Practice Address - Country:US
Practice Address - Phone:248-924-3752
Practice Address - Fax:248-924-3760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-03
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010099473336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2377352OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MI1134473713Medicaid
MI6743500001Medicare NSC