Provider Demographics
NPI:1972824126
Name:ST CLAIR PHARMACY LLC
Entity Type:Organization
Organization Name:ST CLAIR PHARMACY LLC
Other - Org Name:PHARMOR PHARMACY- ST. CLAIR SHORES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CHIEF PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MURSALA
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMED
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:586-443-5180
Mailing Address - Street 1:28001 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1561
Mailing Address - Country:US
Mailing Address - Phone:586-443-5180
Mailing Address - Fax:
Practice Address - Street 1:28001 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1561
Practice Address - Country:US
Practice Address - Phone:586-443-5180
Practice Address - Fax:586-443-5185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-22
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010093733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2125470OtherPK