Provider Demographics
NPI:1508974973
Name:PINE KNOB PHARMACY 6 INC
Entity Type:Organization
Organization Name:PINE KNOB PHARMACY 6 INC
Other - Org Name:PINE KNOB SAV MOR PHARMACY #6
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:PLAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:248-253-0521
Mailing Address - Street 1:1701 BALDWIN AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48340
Mailing Address - Country:US
Mailing Address - Phone:248-253-0521
Mailing Address - Fax:248-253-0542
Practice Address - Street 1:1701 BALDWIN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48340
Practice Address - Country:US
Practice Address - Phone:248-253-0521
Practice Address - Fax:248-253-0542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-27
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5407550001332B00000X
MI53010081163336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2366626OtherNCPDP
MI2366626Medicaid
MI5407550001Medicare NSC