Provider Demographics
NPI:1275575847
Name:CLIO ROAD PHARMACY INC
Entity Type:Organization
Organization Name:CLIO ROAD PHARMACY INC
Other - Org Name:CLIO ROAD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP RDO
Authorized Official - Prefix:
Authorized Official - First Name:SELMA
Authorized Official - Middle Name:
Authorized Official - Last Name:DZELIL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:815-715-8502
Mailing Address - Street 1:4902 CLIO RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48504-1898
Mailing Address - Country:US
Mailing Address - Phone:810-789-7084
Mailing Address - Fax:810-789-7088
Practice Address - Street 1:4902 CLIO RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48504-1898
Practice Address - Country:US
Practice Address - Phone:810-789-7084
Practice Address - Fax:810-789-7088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010075933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2364242Medicaid
2046181OtherPK
4629510001Medicare NSC