Provider Demographics
NPI:1942767660
Name:SOUTHGATE FAMILY PHARMACY, LLC
Entity Type:Organization
Organization Name:SOUTHGATE FAMILY PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AHMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:ATTALLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-587-2944
Mailing Address - Street 1:15450 NORTHLINE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-2490
Mailing Address - Country:US
Mailing Address - Phone:734-720-7480
Mailing Address - Fax:734-720-7943
Practice Address - Street 1:15450 NORTHLINE RD STE 102
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2490
Practice Address - Country:US
Practice Address - Phone:734-720-7480
Practice Address - Fax:734-720-7943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-28
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy