Provider Demographics
NPI:1922421528
Name:BUCKLEYS EASTSIDE PHARMACY LLC
Entity Type:Organization
Organization Name:BUCKLEYS EASTSIDE PHARMACY LLC
Other - Org Name:BUCKLEY'S PHARMACY #104
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF CLINICAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-971-5030
Mailing Address - Street 1:15014 E 8 MILE RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48205-1352
Mailing Address - Country:US
Mailing Address - Phone:313-245-0300
Mailing Address - Fax:313-245-0330
Practice Address - Street 1:15014 E 8 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-1352
Practice Address - Country:US
Practice Address - Phone:313-245-0300
Practice Address - Fax:313-245-0330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X, 3336C0004X
MI53010103113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2144115OtherPK