Provider Demographics
NPI:1881100931
Name:MEDSHOP PHARMACY LLC
Entity type:Organization
Organization Name:MEDSHOP PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ANNAMALAI
Authorized Official - Middle Name:
Authorized Official - Last Name:PERUMAL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:248-268-1714
Mailing Address - Street 1:1964 W 11 MILE RD STE C
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-3046
Mailing Address - Country:US
Mailing Address - Phone:248-268-1714
Mailing Address - Fax:248-268-1634
Practice Address - Street 1:1964 W 11 MILE RD STE C
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-3046
Practice Address - Country:US
Practice Address - Phone:248-268-1714
Practice Address - Fax:248-268-1634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-26
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336C0003X
MI53010113533336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2176962OtherPK