Provider Demographics
NPI:1356584346
Name:ONECARE PHARMACY LLC
Entity type:Organization
Organization Name:ONECARE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PIERRE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUTROS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:248-361-6868
Mailing Address - Street 1:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48012-1239
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1744 W MAPLE RD
Practice Address - Street 2:STE B
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-1545
Practice Address - Country:US
Practice Address - Phone:248-361-6868
Practice Address - Fax:248-817-2297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-07
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336S0011X
MI53010091013336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2119733OtherPK
MI7118950001Medicare NSC