Provider Demographics
NPI:1417368267
Name:LIVONIA PHARMACY LLC
Entity Type:Organization
Organization Name:LIVONIA PHARMACY LLC
Other - Org Name:LIVONIA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROSAIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:KAVURI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:734-744-8110
Mailing Address - Street 1:17888 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-3104
Mailing Address - Country:US
Mailing Address - Phone:734-744-8110
Mailing Address - Fax:734-744-8114
Practice Address - Street 1:17888 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-3104
Practice Address - Country:US
Practice Address - Phone:734-744-8110
Practice Address - Fax:734-744-8114
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIVONIA PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-14
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010104343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy