Provider Demographics
NPI:1417328436
Name:UNIVERSAL GRACE PHARMACY LLC
Entity Type:Organization
Organization Name:UNIVERSAL GRACE PHARMACY LLC
Other - Org Name:UNIVERSAL GRACE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:NOFAL
Authorized Official - Middle Name:
Authorized Official - Last Name:CHOLAG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-999-5951
Mailing Address - Street 1:31500 DEQUINDRE RD STE 300
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-1057
Mailing Address - Country:US
Mailing Address - Phone:586-999-5951
Mailing Address - Fax:586-999-5956
Practice Address - Street 1:31500 DEQUINDRE RD STE 300
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-1057
Practice Address - Country:US
Practice Address - Phone:586-999-5951
Practice Address - Fax:586-999-5956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-16
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MI53010107513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2154721OtherPK