Provider Demographics
NPI:1497598759
Name:PRESTIGE SPECIALTY PHARMACY 103 LLC
Entity type:Organization
Organization Name:PRESTIGE SPECIALTY PHARMACY 103 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:A
Authorized Official - Middle Name:
Authorized Official - Last Name:H
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-390-3626
Mailing Address - Street 1:5815 17 MILE RD STE C
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-6873
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5815 17 MILE RD STE C
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-6873
Practice Address - Country:US
Practice Address - Phone:586-800-8003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-14
Last Update Date:2024-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy