Provider Demographics
NPI:1619131141
Name:DEARBORN COMMUNITY PHARMACY LLC
Entity Type:Organization
Organization Name:DEARBORN COMMUNITY PHARMACY LLC
Other - Org Name:INDEPENDENT COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TOBORE
Authorized Official - Middle Name:
Authorized Official - Last Name:UGBOSU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-931-2133
Mailing Address - Street 1:8742 W WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-4043
Mailing Address - Country:US
Mailing Address - Phone:313-931-2133
Mailing Address - Fax:313-931-3509
Practice Address - Street 1:8742 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-4043
Practice Address - Country:US
Practice Address - Phone:313-931-2133
Practice Address - Fax:313-931-3509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-14
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301008886332B00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies