Provider Demographics
NPI:1568871382
Name:PELHAM PHARMACY
Entity Type:Organization
Organization Name:PELHAM PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RPH
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAIDAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-565-2745
Mailing Address - Street 1:3815 PELHAM ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3852
Mailing Address - Country:US
Mailing Address - Phone:313-565-2745
Mailing Address - Fax:313-565-2747
Practice Address - Street 1:3815 PELHAM ST
Practice Address - Street 2:SUITE 3
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3852
Practice Address - Country:US
Practice Address - Phone:313-565-2745
Practice Address - Fax:313-565-2747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010105303336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy