Provider Demographics
NPI:1891803268
Name:PINE KNOB PHARMACY #3, INC.
Entity Type:Organization
Organization Name:PINE KNOB PHARMACY #3, INC.
Other - Org Name:SAV-MOR #38 PINE KNOB #3
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RAY
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:BULLARD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:248-620-3588
Mailing Address - Street 1:6770 DIXIE HIGHWAY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346
Mailing Address - Country:US
Mailing Address - Phone:248-620-3588
Mailing Address - Fax:248-620-0037
Practice Address - Street 1:6770 DIXIE HIGHWAY
Practice Address - Street 2:SUITE 201
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346
Practice Address - Country:US
Practice Address - Phone:248-620-3588
Practice Address - Fax:248-620-0037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010062323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2354126OtherOTHER ID NUMBER
2354126OtherNABP/NCPDP
2354126OtherNABP/NCPDP