Provider Demographics
NPI:1639264229
Name:PRESCRIPTIONGIANT LLC
Entity Type:Organization
Organization Name:PRESCRIPTIONGIANT LLC
Other - Org Name:PRESCRIPTIONGIANT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYRONE
Authorized Official - Middle Name:
Authorized Official - Last Name:SQUIRES
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:866-499-1940
Mailing Address - Street 1:2620 CENTENNIAL RD STE G
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43617-1800
Mailing Address - Country:US
Mailing Address - Phone:866-499-1940
Mailing Address - Fax:248-608-6418
Practice Address - Street 1:1078 E AVON RD
Practice Address - Street 2:STE 221
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-2424
Practice Address - Country:US
Practice Address - Phone:866-499-1940
Practice Address - Fax:248-608-6418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X, 3336L0003X, 3336S0011X
OH0219572503336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2366929Medicaid
2366929OtherNCPDP PROVIDER IDENTIFICATION NUMBER
5893280001Medicare NSC