Provider Demographics
NPI:1639114333
Name:PROFESSIONAL PHARMACY SERVICES-II INC.
Entity Type:Organization
Organization Name:PROFESSIONAL PHARMACY SERVICES-II INC.
Other - Org Name:NORTHEAST PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:STAFF
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILCZYNSKI
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:586-263-6400
Mailing Address - Street 1:43900 GARFIELD RD
Mailing Address - Street 2:STE 102
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1128
Mailing Address - Country:US
Mailing Address - Phone:586-263-6400
Mailing Address - Fax:586-263-9463
Practice Address - Street 1:43900 GARFIELD RD
Practice Address - Street 2:STE 102
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-1128
Practice Address - Country:US
Practice Address - Phone:586-263-6400
Practice Address - Fax:586-263-9463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MI53010069293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2359544Medicaid
2044386OtherPK