Provider Demographics
NPI:1336383363
Name:PINE KNOB PHARMACY 1 INC
Entity Type:Organization
Organization Name:PINE KNOB PHARMACY 1 INC
Other - Org Name:SAV-MOR 51 PINE KNOB PHARMACY 1
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:J
Authorized Official - Last Name:PLAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:248-384-8050
Mailing Address - Street 1:5701 BOW POINTE DR
Mailing Address - Street 2:STE 130
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3198
Mailing Address - Country:US
Mailing Address - Phone:248-384-8050
Mailing Address - Fax:248-384-8055
Practice Address - Street 1:5701 BOW POINTE DR
Practice Address - Street 2:STE 130
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-3198
Practice Address - Country:US
Practice Address - Phone:248-384-8050
Practice Address - Fax:248-384-8055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-21
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010090893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2119843OtherPK