Provider Demographics
NPI:1376846980
Name:SAV-MART PHARMACY-GRATIOT LLC
Entity Type:Organization
Organization Name:SAV-MART PHARMACY-GRATIOT LLC
Other - Org Name:SAV-MART PHARMACY II
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABDO
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOUBAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-923-0007
Mailing Address - Street 1:23815 NORTHWESTERN HWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-7738
Mailing Address - Country:US
Mailing Address - Phone:248-663-3380
Mailing Address - Fax:248-223-1061
Practice Address - Street 1:7011 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-1973
Practice Address - Country:US
Practice Address - Phone:313-923-0007
Practice Address - Fax:313-923-0098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-21
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010094093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2127796OtherPK