Provider Demographics
NPI:1548750714
Name:PRESTIGE SPECIALTY PHARMACY LLC
Entity Type:Organization
Organization Name:PRESTIGE SPECIALTY PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AMRO
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARAFELDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-742-7621
Mailing Address - Street 1:3739 15 MILE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310
Mailing Address - Country:US
Mailing Address - Phone:877-742-7621
Mailing Address - Fax:586-883-9388
Practice Address - Street 1:3739 15 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310
Practice Address - Country:US
Practice Address - Phone:877-742-7621
Practice Address - Fax:586-883-9388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-14
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1306340955Medicaid
2177646OtherPK