Provider Demographics
NPI:1417332065
Name:METRO MEDICAL PHARMACY LLC
Entity Type:Organization
Organization Name:METRO MEDICAL PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:NASR
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-894-2888
Mailing Address - Street 1:6461 W WARREN AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48210-1176
Mailing Address - Country:US
Mailing Address - Phone:313-894-2888
Mailing Address - Fax:313-894-2868
Practice Address - Street 1:6461 W WARREN AVE STE 200
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48210-1176
Practice Address - Country:US
Practice Address - Phone:313-894-2888
Practice Address - Fax:313-894-2868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-24
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010108963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy