Provider Demographics
NPI:1174040026
Name:DETROIT PHARMACY LLC
Entity Type:Organization
Organization Name:DETROIT PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PUNAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KUMARI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-922-6942
Mailing Address - Street 1:6455 GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-1808
Mailing Address - Country:US
Mailing Address - Phone:313-922-6942
Mailing Address - Fax:
Practice Address - Street 1:6455 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-1808
Practice Address - Country:US
Practice Address - Phone:313-922-6942
Practice Address - Fax:313-922-6941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-22
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010112173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy