Provider Demographics
NPI:1386004216
Name:PRESTIGE MEDICAL, LLC
Entity Type:Organization
Organization Name:PRESTIGE MEDICAL, LLC
Other - Org Name:PRESTIGE MEDICAL, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, AO
Authorized Official - Prefix:
Authorized Official - First Name:FATIMA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-879-5047
Mailing Address - Street 1:7940 N LILLEY RD
Mailing Address - Street 2:SUITE A-110
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2432
Mailing Address - Country:US
Mailing Address - Phone:313-879-5047
Mailing Address - Fax:888-726-0494
Practice Address - Street 1:7940 N LILLEY RD
Practice Address - Street 2:SUITE A-110
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2432
Practice Address - Country:US
Practice Address - Phone:313-879-5047
Practice Address - Fax:888-726-0494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-04
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MI53010108853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacyGroup - Multi-Specialty
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2158908OtherPK