Provider Demographics
NPI:1821439621
Name:HIGHLAND PARK GLORY PHARMACY LLC
Entity Type:Organization
Organization Name:HIGHLAND PARK GLORY PHARMACY LLC
Other - Org Name:PHARMOR PHARMACY- HIGHLAND PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:
Authorized Official - Last Name:SOHOUBAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-663-3380
Mailing Address - Street 1:23815 NORTHWESTERN HWY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-7738
Mailing Address - Country:US
Mailing Address - Phone:248-996-8441
Mailing Address - Fax:248-996-8827
Practice Address - Street 1:23815 NORTHWESTERN HWY STE 120
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-7738
Practice Address - Country:US
Practice Address - Phone:248-996-8441
Practice Address - Fax:248-996-8827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-10
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010100443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1821439621Medicaid
2141090OtherPK