Provider Demographics
NPI:1588832760
Name:PINE KNOB PHARMACY #3
Entity Type:Organization
Organization Name:PINE KNOB PHARMACY #3
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:PLAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:248-620-3588
Mailing Address - Street 1:6770 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-2087
Mailing Address - Country:US
Mailing Address - Phone:248-620-3588
Mailing Address - Fax:
Practice Address - Street 1:6770 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2087
Practice Address - Country:US
Practice Address - Phone:248-620-3588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies