Provider Demographics
NPI:1821573130
Name:MATRIX PHARMACY,LLC
Entity Type:Organization
Organization Name:MATRIX PHARMACY,LLC
Other - Org Name:MATRIX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMEELA
Authorized Official - Middle Name:
Authorized Official - Last Name:HEPBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-231-6627
Mailing Address - Street 1:5827 E 13 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-1512
Mailing Address - Country:US
Mailing Address - Phone:586-883-6047
Mailing Address - Fax:586-883-6159
Practice Address - Street 1:5827 E 13 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-1512
Practice Address - Country:US
Practice Address - Phone:586-883-6047
Practice Address - Fax:586-883-6159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-02
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1396204129Medicaid
MI1821573130Medicaid