Provider Demographics
NPI:1659626646
Name:GRAND BLANC COMMUNITY PHARMACY LLC
Entity Type:Organization
Organization Name:GRAND BLANC COMMUNITY PHARMACY LLC
Other - Org Name:GRAND BLANC COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AHMED
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-720-2990
Mailing Address - Street 1:1230 S LINDEN RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3459
Mailing Address - Country:US
Mailing Address - Phone:810-720-2990
Mailing Address - Fax:810-720-2993
Practice Address - Street 1:12741 S SAGINAW ST STE 802
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-2460
Practice Address - Country:US
Practice Address - Phone:810-953-0710
Practice Address - Fax:810-953-0715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-17
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010100023336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2138866OtherPK