Provider Demographics
NPI:1932611639
Name:CHESANING RX LLC
Entity Type:Organization
Organization Name:CHESANING RX LLC
Other - Org Name:FAMILY REXALL RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:3RD PARTY COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-751-7979
Mailing Address - Street 1:6689 ORCHARD LAKE RD # 168
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3404
Mailing Address - Country:US
Mailing Address - Phone:248-862-6148
Mailing Address - Fax:248-862-6132
Practice Address - Street 1:202 W BROAD ST
Practice Address - Street 2:
Practice Address - City:CHESANING
Practice Address - State:MI
Practice Address - Zip Code:48616-1205
Practice Address - Country:US
Practice Address - Phone:989-865-0316
Practice Address - Fax:989-865-0317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-02
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010108103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1932611639Medicaid
FSRX1833636OtherFLEXSCRIPT