Provider Demographics
NPI:1952679599
Name:PRIMISHA PHRAMACY LLC
Entity Type:Organization
Organization Name:PRIMISHA PHRAMACY LLC
Other - Org Name:PRIMISHA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PRITESH
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:248-925-8496
Mailing Address - Street 1:750 FLETCHER DR
Mailing Address - Street 2:STE 103
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-4703
Mailing Address - Country:US
Mailing Address - Phone:847-742-6700
Mailing Address - Fax:847-742-6767
Practice Address - Street 1:750 FLETCHER DR
Practice Address - Street 2:STE 103
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4703
Practice Address - Country:US
Practice Address - Phone:847-742-6700
Practice Address - Fax:847-742-6767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-11
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL054.0178073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2133046OtherPK
IL453069834-60123-01Medicaid
IL453069834-60123-01Medicaid