Provider Demographics
NPI:1255706149
Name:RITEAID PHARMACY
Entity type:Organization
Organization Name:RITEAID PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:HIMANSHU
Authorized Official - Middle Name:H
Authorized Official - Last Name:SHUKLA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:734-233-0823
Mailing Address - Street 1:18430 FENKELL ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-2301
Mailing Address - Country:US
Mailing Address - Phone:313-837-2340
Mailing Address - Fax:313-837-0884
Practice Address - Street 1:18430 FENKELL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-2301
Practice Address - Country:US
Practice Address - Phone:313-837-2340
Practice Address - Fax:313-837-0884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-03
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302034906183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302034906Medicaid