Provider Demographics
NPI:1619410321
Name:RED CAP PHARMACY 001 LLC
Entity Type:Organization
Organization Name:RED CAP PHARMACY 001 LLC
Other - Org Name:RED CAP PHARMACY 001
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMAD
Authorized Official - Middle Name:ISSA
Authorized Official - Last Name:ABOUKHODR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-879-4877
Mailing Address - Street 1:214 N. WEST AVE STE A
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201
Mailing Address - Country:US
Mailing Address - Phone:517-879-4877
Mailing Address - Fax:517-879-1873
Practice Address - Street 1:214 N WEST AVE STE A
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1903
Practice Address - Country:US
Practice Address - Phone:517-879-4877
Practice Address - Fax:517-879-1873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-29
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010110543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166443OtherPK