Provider Demographics
NPI:1831441971
Name:PREMIER HOME PHARMACY OF MI
Entity type:Organization
Organization Name:PREMIER HOME PHARMACY OF MI
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SYED
Authorized Official - Middle Name:
Authorized Official - Last Name:RAZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-658-8985
Mailing Address - Street 1:23874 KEAN ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1804
Mailing Address - Country:US
Mailing Address - Phone:313-887-9111
Mailing Address - Fax:313-887-4229
Practice Address - Street 1:23874 KEAN ST
Practice Address - Street 2:SUITE 120
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1804
Practice Address - Country:US
Practice Address - Phone:313-887-9111
Practice Address - Fax:313-887-4229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-13
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 333600000X
MI53010100753336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1831441971Medicaid
2137422OtherPK