Provider Demographics
NPI:1962850248
Name:WESTERN WAYNE PHARMACY LLC
Entity Type:Organization
Organization Name:WESTERN WAYNE PHARMACY LLC
Other - Org Name:WESTERN WAYNE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, AO
Authorized Official - Prefix:
Authorized Official - First Name:WAHID
Authorized Official - Middle Name:
Authorized Official - Last Name:MAKKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-402-7663
Mailing Address - Street 1:2700 HAMLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:MI
Mailing Address - Zip Code:48141-2206
Mailing Address - Country:US
Mailing Address - Phone:313-914-3434
Mailing Address - Fax:313-914-3673
Practice Address - Street 1:2700 HAMLIN BLVD
Practice Address - Street 2:
Practice Address - City:INKSTER
Practice Address - State:MI
Practice Address - Zip Code:48141-2206
Practice Address - Country:US
Practice Address - Phone:313-914-3434
Practice Address - Fax:313-914-3673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-27
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MI53010109133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1962850248Medicaid
2160269OtherPK