Provider Demographics
NPI:1629527734
Name:DEARBORN COMMUNITY CARE PHARMACY LLC
Entity Type:Organization
Organization Name:DEARBORN COMMUNITY CARE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:NABIL
Authorized Official - Middle Name:MOHSEN MOHSEN
Authorized Official - Last Name:AL-SUBARI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:313-558-2121
Mailing Address - Street 1:15120 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3768
Mailing Address - Country:US
Mailing Address - Phone:313-558-2121
Mailing Address - Fax:313-558-2020
Practice Address - Street 1:15120 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3768
Practice Address - Country:US
Practice Address - Phone:313-558-2121
Practice Address - Fax:313-558-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-30
Last Update Date:2017-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010110073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty