Provider Demographics
NPI:1326588294
Name:LAKEWOOD FAMILY PHARMACY LLC
Entity Type:Organization
Organization Name:LAKEWOOD FAMILY PHARMACY LLC
Other - Org Name:DEARBORN FAMILY PHARMACY LTC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HASSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ISMAIL
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:313-982-3770
Mailing Address - Street 1:17000 EXECUTIVE PLAZA DR STE 209
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2793
Mailing Address - Country:US
Mailing Address - Phone:313-982-3770
Mailing Address - Fax:313-982-3771
Practice Address - Street 1:17000 EXECUTIVE PLAZA DR STE 209
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2793
Practice Address - Country:US
Practice Address - Phone:313-982-3770
Practice Address - Fax:313-982-3771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-27
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X, 3336S0011X, 3336C0004X
MI53010111073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2383052Medicaid