Provider Demographics
NPI:1629341102
Name:PORT HURON PHARMACY, LLC
Entity Type:Organization
Organization Name:PORT HURON PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANKUR
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-632-8182
Mailing Address - Street 1:515 10TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-4404
Mailing Address - Country:US
Mailing Address - Phone:810-989-5990
Mailing Address - Fax:810-989-5992
Practice Address - Street 1:515 10TH ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-4404
Practice Address - Country:US
Practice Address - Phone:810-989-5990
Practice Address - Fax:810-989-5992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========Medicaid