Provider Demographics
NPI:1790866416
Name:LIVERNOIS FAMILY PHARMACY
Entity Type:Organization
Organization Name:LIVERNOIS FAMILY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST ENCHARGE
Authorized Official - Prefix:
Authorized Official - First Name:SHEHRBANO
Authorized Official - Middle Name:
Authorized Official - Last Name:HUSSAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-341-3511
Mailing Address - Street 1:182554 LIVERNOIS AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221
Mailing Address - Country:US
Mailing Address - Phone:313-341-3511
Mailing Address - Fax:313-341-3624
Practice Address - Street 1:18254 LIVERNOIS AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-4214
Practice Address - Country:US
Practice Address - Phone:313-341-3511
Practice Address - Fax:313-341-3624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301007422333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2362957OtherNABP NUMBER
MI4192614Medicaid
MI4770683OtherMICHIGAN MEDICAID DME
MI4192614Medicaid