Provider Demographics
NPI:1588010334
Name:SELECT CARE PHARMACY LLC
Entity Type:Organization
Organization Name:SELECT CARE PHARMACY LLC
Other - Org Name:SELECT CARE PHARMACY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/AO
Authorized Official - Prefix:
Authorized Official - First Name:VIRENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAIDHANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-246-7997
Mailing Address - Street 1:28003 JOHN R RD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-2809
Mailing Address - Country:US
Mailing Address - Phone:248-246-7997
Mailing Address - Fax:245-565-2029
Practice Address - Street 1:28003 JOHN R RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-2809
Practice Address - Country:US
Practice Address - Phone:248-246-7997
Practice Address - Fax:245-565-2029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-11
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MI53010109433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI82265105Medicaid
2160107OtherPK