Provider Demographics
NPI:1508316605
Name:CORKTOWN PHARMACY LLC
Entity Type:Organization
Organization Name:CORKTOWN PHARMACY LLC
Other - Org Name:CORKTOWN PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:EMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:SALEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-414-7170
Mailing Address - Street 1:23487 HILL ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-2382
Mailing Address - Country:US
Mailing Address - Phone:313-414-7170
Mailing Address - Fax:
Practice Address - Street 1:1726 HOWARD ST
Practice Address - Street 2:SUITE 200
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48216-1921
Practice Address - Country:US
Practice Address - Phone:313-414-7170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-12
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2164664OtherPK