Provider Demographics
NPI:1881909869
Name:GREAT LAKES SAV-RITE
Entity type:Organization
Organization Name:GREAT LAKES SAV-RITE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OUSSAMA
Authorized Official - Middle Name:
Authorized Official - Last Name:ABDOU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-827-9999
Mailing Address - Street 1:1770 FORT ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-1904
Mailing Address - Country:US
Mailing Address - Phone:313-827-9999
Mailing Address - Fax:313-827-0999
Practice Address - Street 1:1770 FORT ST
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-1904
Practice Address - Country:US
Practice Address - Phone:313-827-9999
Practice Address - Fax:313-827-0999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-13
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010093983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2374471OtherNCPDP PROVIDER IDENTIFICATION NUMBER