Provider Demographics
NPI:1831100478
Name:BELAVISTA PHARMACY INC
Entity Type:Organization
Organization Name:BELAVISTA PHARMACY INC
Other - Org Name:BELAVISTA PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:NASSAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-485-1411
Mailing Address - Street 1:347 INKSTER RD
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:MI
Mailing Address - Zip Code:48141-1208
Mailing Address - Country:US
Mailing Address - Phone:313-563-5300
Mailing Address - Fax:313-563-5353
Practice Address - Street 1:347 INKSTER RD
Practice Address - Street 2:
Practice Address - City:INKSTER
Practice Address - State:MI
Practice Address - Zip Code:48141-1208
Practice Address - Country:US
Practice Address - Phone:313-563-5300
Practice Address - Fax:313-563-5353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
MI53010078853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2365814OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MI874667074Medicaid
MI5285250001Medicare NSC