Provider Demographics
NPI:1558700138
Name:SAM'S PHARMACY PLLC
Entity Type:Organization
Organization Name:SAM'S PHARMACY PLLC
Other - Org Name:SAM'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BASSAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HARATI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-340-7777
Mailing Address - Street 1:14470 LIVERNOIS AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-2005
Mailing Address - Country:US
Mailing Address - Phone:313-340-7777
Mailing Address - Fax:313-340-4449
Practice Address - Street 1:14470 LIVERNOIS AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-2005
Practice Address - Country:US
Practice Address - Phone:313-340-7777
Practice Address - Fax:313-899-7779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-18
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010101183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140569OtherPK