Provider Demographics
NPI:1518392281
Name:EL NOOR LLC
Entity Type:Organization
Organization Name:EL NOOR LLC
Other - Org Name:PREMIERX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ALBOUSTANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-957-9100
Mailing Address - Street 1:20292 MIDDLEBELT RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-2002
Mailing Address - Country:US
Mailing Address - Phone:248-957-9100
Mailing Address - Fax:248-957-9111
Practice Address - Street 1:20292 MIDDLEBELT RD
Practice Address - Street 2:SUITE B
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-2002
Practice Address - Country:US
Practice Address - Phone:248-957-9100
Practice Address - Fax:248-957-9111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-12
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010102843336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1518392281Medicaid
2142165OtherPK