Provider Demographics
NPI:1164437992
Name:ROSA PARK MEDICAL PHARMACY LLC
Entity Type:Organization
Organization Name:ROSA PARK MEDICAL PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:AHMED
Authorized Official - Middle Name:
Authorized Official - Last Name:SAID
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:313-377-8876
Mailing Address - Street 1:8665 ROSA PARKS BOULAVARD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48206
Mailing Address - Country:US
Mailing Address - Phone:313-361-8800
Mailing Address - Fax:313-361-8875
Practice Address - Street 1:8665 ROSA PARKS BOULAVARD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48206
Practice Address - Country:US
Practice Address - Phone:313-361-8800
Practice Address - Fax:313-361-8875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MI53010084353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2042324OtherPK
MI1164437992Medicaid
5749690001Medicare NSC