Provider Demographics
NPI:1982054383
Name:DEARBORN RX PHARMACY LLC
Entity Type:Organization
Organization Name:DEARBORN RX PHARMACY LLC
Other - Org Name:DEARBORN RX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HD OF PHCY OPS, PHCY MGR, PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:KETAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SAGGAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-655-6052
Mailing Address - Street 1:10633 W WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-8010
Mailing Address - Country:US
Mailing Address - Phone:313-633-0683
Mailing Address - Fax:313-438-0150
Practice Address - Street 1:10633 W WARREN AVE STE A
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-8010
Practice Address - Country:US
Practice Address - Phone:313-633-0683
Practice Address - Fax:313-438-0150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-16
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010109583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2160572OtherPK