Provider Demographics
NPI:1164692356
Name:GREAT LAKES MEDICAL PHARMACY LLC
Entity Type:Organization
Organization Name:GREAT LAKES MEDICAL PHARMACY LLC
Other - Org Name:ALL AMERICAN MEDICAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:RAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:LAZEKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-455-3836
Mailing Address - Street 1:23247 PINEWOOD ST
Mailing Address - Street 2:STE 100
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-4754
Mailing Address - Country:US
Mailing Address - Phone:866-576-5040
Mailing Address - Fax:877-448-0633
Practice Address - Street 1:23247 PINEWOOD ST
Practice Address - Street 2:STE 100
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-4754
Practice Address - Country:US
Practice Address - Phone:954-381-7146
Practice Address - Fax:877-448-0633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010102343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2144902OtherPK
MI1164692356Medicaid