Provider Demographics
NPI:1134594898
Name:BLOSSOM CARE PHARMACY LLC
Entity type:Organization
Organization Name:BLOSSOM CARE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:IMANE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALZAROUI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:313-377-0793
Mailing Address - Street 1:5250 AUTO CLUB DR STE 160
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2619
Mailing Address - Country:US
Mailing Address - Phone:313-436-5513
Mailing Address - Fax:313-436-5405
Practice Address - Street 1:5250 AUTO CLUB DR STE 160
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2619
Practice Address - Country:US
Practice Address - Phone:313-436-5513
Practice Address - Fax:313-436-5405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-07
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MI53010107683336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2381363Medicaid
2155809OtherPK