Provider Demographics
NPI:1598910150
Name:HAMTRAMCK MEDICAL PHARMACY LLC
Entity Type:Organization
Organization Name:HAMTRAMCK MEDICAL PHARMACY LLC
Other - Org Name:PHARMOR PHARMACY-HAMTRAMCK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:MURSALA
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-871-1010
Mailing Address - Street 1:3301 HOLBROOK ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:HAMTRAMCK
Mailing Address - State:MI
Mailing Address - Zip Code:48212-3519
Mailing Address - Country:US
Mailing Address - Phone:313-871-1010
Mailing Address - Fax:313-871-1011
Practice Address - Street 1:3301 HOLBROOK ST STE B
Practice Address - Street 2:
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48212-3519
Practice Address - Country:US
Practice Address - Phone:313-871-1010
Practice Address - Fax:313-871-1011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-24
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010089943336C0003X
3336C0004X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2117925OtherPK