Provider Demographics
NPI:1346793817
Name:FERNDALE FAMILY PHARMACY INC
Entity Type:Organization
Organization Name:FERNDALE FAMILY PHARMACY INC
Other - Org Name:FERNDALE FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, OPERATING OFFICER, AO
Authorized Official - Prefix:
Authorized Official - First Name:AMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHRAIZAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-415-7754
Mailing Address - Street 1:753 W 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-1217
Mailing Address - Country:US
Mailing Address - Phone:248-565-8031
Mailing Address - Fax:248-565-8358
Practice Address - Street 1:753 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-1217
Practice Address - Country:US
Practice Address - Phone:248-565-8031
Practice Address - Fax:248-565-8358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-01
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010109863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1346793817Medicaid
2162361OtherPK