Provider Demographics
NPI:1629389036
Name:CHAMPAIGN PHARMACY LLC
Entity Type:Organization
Organization Name:CHAMPAIGN PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMER
Authorized Official - Middle Name:
Authorized Official - Last Name:ALAME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-382-1600
Mailing Address - Street 1:14741 CHAMPAIGN RD
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-1616
Mailing Address - Country:US
Mailing Address - Phone:313-382-1600
Mailing Address - Fax:313-382-1602
Practice Address - Street 1:14741 CHAMPAIGN RD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-1616
Practice Address - Country:US
Practice Address - Phone:313-382-1600
Practice Address - Fax:313-382-1602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-30
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6481080001Medicare NSC