Provider Demographics
NPI:1962495796
Name:KNIGHT DRUGS WEST WARREN, INC.
Entity Type:Organization
Organization Name:KNIGHT DRUGS WEST WARREN, INC.
Other - Org Name:KNIGHT DRUGS MCNICHOLS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEJONGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-540-8066
Mailing Address - Street 1:2520 INDUSTRIAL ROW DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-7035
Mailing Address - Country:US
Mailing Address - Phone:248-540-8066
Mailing Address - Fax:248-540-0112
Practice Address - Street 1:4321 E MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48212-1720
Practice Address - Country:US
Practice Address - Phone:313-369-4399
Practice Address - Fax:313-606-8489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301006762333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2358100OtherNCPDP
MI1962495796OtherNPI
MI3454310Medicaid
MI4148812Medicare ID - Type Unspecified
MI4246040001Medicare NSC