Provider Demographics
NPI:1326701574
Name:LINCOLN RX OF FERNDALE LLC
Entity Type:Organization
Organization Name:LINCOLN RX OF FERNDALE LLC
Other - Org Name:LINCOLN RX PHARMACY 2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARWAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ISA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-990-5121
Mailing Address - Street 1:600 W 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-2969
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-2969
Practice Address - Country:US
Practice Address - Phone:248-990-5121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1326701574Medicaid