Provider Demographics
NPI:1376842765
Name:BUCKLEY BRANDS LLC
Entity Type:Organization
Organization Name:BUCKLEY BRANDS LLC
Other - Org Name:BUCKLEY'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:313-971-5030
Mailing Address - Street 1:18021 CONANT ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234
Mailing Address - Country:US
Mailing Address - Phone:313-368-1000
Mailing Address - Fax:313-368-1068
Practice Address - Street 1:18021 CONANT ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234
Practice Address - Country:US
Practice Address - Phone:313-368-1000
Practice Address - Fax:313-368-1068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-24
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010095383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2365600Medicaid
2375283OtherNCPDP PROVIDER IDENTIFICATION NUMBER