Provider Demographics
NPI:1255324059
Name:KD PHARMACY, INC.
Entity Type:Organization
Organization Name:KD PHARMACY, INC.
Other - Org Name:KNIGHT DRUGS GRATIOT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:D'AGNILLO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:313-571-4450
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:313-571-4450
Mailing Address - Fax:313-571-4451
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:313-571-4450
Practice Address - Fax:313-571-4451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301005179333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2586600Medicaid
MI2345507OtherNCPDP
MI2702432Medicare ID - Type Unspecified