Provider Demographics
NPI:1003924465
Name:WALNUT ASSOCIATES I LLC
Entity type:Organization
Organization Name:WALNUT ASSOCIATES I LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-354-0282
Mailing Address - Street 1:3390 WEST ROAD
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-2323
Mailing Address - Country:US
Mailing Address - Phone:734-676-6622
Mailing Address - Fax:734-676-5725
Practice Address - Street 1:3390 WEST ROAD
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183
Practice Address - Country:US
Practice Address - Phone:734-676-6622
Practice Address - Fax:734-676-5725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-27
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010064073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2308054Medicaid
2308054OtherOTHER ID NUMBER
0560950001Medicare NSC