Provider Demographics
NPI:1013453950
Name:ABE S PHARMACY LLC
Entity Type:Organization
Organization Name:ABE S PHARMACY LLC
Other - Org Name:ABE'S DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:HUSSEIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:313-686-8666
Mailing Address - Street 1:13760 E 12 MILE RD STE B
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-3751
Mailing Address - Country:US
Mailing Address - Phone:586-362-8404
Mailing Address - Fax:586-251-0322
Practice Address - Street 1:13760 E 12 MILE RD STE B
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-3751
Practice Address - Country:US
Practice Address - Phone:586-362-8404
Practice Address - Fax:586-251-0322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-17
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010110843336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1013453950Medicaid
2167138OtherPK