Provider Demographics
NPI:1629183652
Name:DURA CORP
Entity Type:Organization
Organization Name:DURA CORP
Other - Org Name:THE MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:RAWAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHADER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:586-268-6266
Mailing Address - Street 1:3979 17 MILE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-6835
Mailing Address - Country:US
Mailing Address - Phone:586-268-6266
Mailing Address - Fax:586-268-6113
Practice Address - Street 1:3979 17 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-6835
Practice Address - Country:US
Practice Address - Phone:586-268-6266
Practice Address - Fax:586-268-6113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301006377333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2355382OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MI3218681Medicaid
MI3218681Medicaid
2355382OtherOTHER ID NUMBER-COMMERCIAL NUMBER