Provider Demographics
NPI:1437202587
Name:CONANT PLAZA PHARMACY LLC
Entity Type:Organization
Organization Name:CONANT PLAZA PHARMACY LLC
Other - Org Name:CONANT PLAZA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:A
Authorized Official - Last Name:BERRI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:313-366-1221
Mailing Address - Street 1:3611 CARPENTER ST
Mailing Address - Street 2:SUITE #3
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48212-2784
Mailing Address - Country:US
Mailing Address - Phone:313-366-1221
Mailing Address - Fax:313-366-2947
Practice Address - Street 1:3611 CARPENTER ST
Practice Address - Street 2:SUITE #3
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48212-2784
Practice Address - Country:US
Practice Address - Phone:313-366-1221
Practice Address - Fax:313-366-2947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-20
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010078433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2365600Medicaid
MI5405190001Medicare NSC