Provider Demographics
NPI:1184750713
Name:CROWN SPECIALTY PHARMACY LLC
Entity type:Organization
Organization Name:CROWN SPECIALTY PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:JAMIL
Authorized Official - Last Name:FAKIH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:313-532-3784
Mailing Address - Street 1:24401 PLYMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-1616
Mailing Address - Country:US
Mailing Address - Phone:313-532-3784
Mailing Address - Fax:313-532-3718
Practice Address - Street 1:24401 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-1616
Practice Address - Country:US
Practice Address - Phone:313-532-3784
Practice Address - Fax:313-532-3718
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CROWN SPECIALTY PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-26
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010102953336C0003X
3336L0003X, 3336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2346802Medicaid
MI=========OtherTAX ID NUMBER