Provider Demographics
NPI:1316367816
Name:VAN BUREN PHARMACEUTICALS LLC
Entity Type:Organization
Organization Name:VAN BUREN PHARMACEUTICALS LLC
Other - Org Name:VAN BUREN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:GEBRE
Authorized Official - Middle Name:
Authorized Official - Last Name:ASHEBIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-325-6318
Mailing Address - Street 1:11650 BELLEVILLE RD STE 103
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-3382
Mailing Address - Country:US
Mailing Address - Phone:734-325-6318
Mailing Address - Fax:734-325-6319
Practice Address - Street 1:11650 BELLEVILLE RD STE 103
Practice Address - Street 2:SUITE 103
Practice Address - City:BELLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48111-3382
Practice Address - Country:US
Practice Address - Phone:734-325-6318
Practice Address - Fax:734-325-6319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-23
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010103923336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0006060728Medicaid
2145405OtherPK