Provider Demographics
NPI:1477310589
Name:PRESTIGE SPECIALTY PHARMACY 102 LLC
Entity Type:Organization
Organization Name:PRESTIGE SPECIALTY PHARMACY 102 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:A
Authorized Official - Middle Name:
Authorized Official - Last Name:H
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-800-8004
Mailing Address - Street 1:5815 17 MILE RD STE B
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-6873
Mailing Address - Country:US
Mailing Address - Phone:586-800-8004
Mailing Address - Fax:877-308-0484
Practice Address - Street 1:5815 17 MILE RD STE B
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-6873
Practice Address - Country:US
Practice Address - Phone:586-800-8004
Practice Address - Fax:877-308-0484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy