Provider Demographics
NPI:1942953112
Name:AVICENNA PHARMACY LLC
Entity Type:Organization
Organization Name:AVICENNA PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:ABATESAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ELMATHIL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:313-986-8150
Mailing Address - Street 1:9610 JOSEPH CAMPAU ST
Mailing Address - Street 2:
Mailing Address - City:HAMTRAMCK
Mailing Address - State:MI
Mailing Address - Zip Code:48212-3440
Mailing Address - Country:US
Mailing Address - Phone:313-285-8070
Mailing Address - Fax:313-338-3196
Practice Address - Street 1:9610 JOSEPH CAMPAU ST
Practice Address - Street 2:
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48212-3440
Practice Address - Country:US
Practice Address - Phone:313-303-7480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-28
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy