Provider Demographics
NPI:1497757355
Name:KNAB PHARMACY INC
Entity Type:Organization
Organization Name:KNAB PHARMACY INC
Other - Org Name:WILTSE'S COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:D
Authorized Official - Middle Name:D
Authorized Official - Last Name:KNAB
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:734-453-4848
Mailing Address - Street 1:330 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-1604
Mailing Address - Country:US
Mailing Address - Phone:734-453-4848
Mailing Address - Fax:734-453-4090
Practice Address - Street 1:330 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1604
Practice Address - Country:US
Practice Address - Phone:734-453-4848
Practice Address - Fax:734-453-4090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-11
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010009653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2310643Medicaid
MI2310643Medicaid