Provider Demographics
NPI:1851674709
Name:FARM FRESH PHARMACY LLC
Entity Type:Organization
Organization Name:FARM FRESH PHARMACY LLC
Other - Org Name:FARM FRESH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HETALBEHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JARIWALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-545-5850
Mailing Address - Street 1:13151 W 10 MILE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-4601
Mailing Address - Country:US
Mailing Address - Phone:248-545-5850
Mailing Address - Fax:248-545-5851
Practice Address - Street 1:13151 W 10 MILE RD STE 1
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-4601
Practice Address - Country:US
Practice Address - Phone:248-545-5850
Practice Address - Fax:248-545-5851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-27
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010096563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2375877OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MI1851674709Medicaid