Provider Demographics
NPI:1275998205
Name:JOHN S LTC PHARMACY INC
Entity Type:Organization
Organization Name:JOHN S LTC PHARMACY INC
Other - Org Name:SHELBY FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:RASHUNTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-461-2900
Mailing Address - Street 1:48887 HAYES RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-4405
Mailing Address - Country:US
Mailing Address - Phone:586-461-2900
Mailing Address - Fax:586-461-2464
Practice Address - Street 1:48887 HAYES RD
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-4405
Practice Address - Country:US
Practice Address - Phone:586-461-2900
Practice Address - Fax:586-461-2464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-17
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X, 3336C0004X
MI53010107833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1275998205Medicaid
2156098OtherPK