Provider Demographics
NPI:1982888947
Name:GREAT LAKES RX SAV MOR PHARMACY
Entity Type:Organization
Organization Name:GREAT LAKES RX SAV MOR PHARMACY
Other - Org Name:GREAT LAKES RX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KHANAFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:133-412-4622
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:
Mailing Address - Fax:
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:2007-12-26
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010087733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2370702OtherNCPDP PROVIDER IDENTIFICATION NUMBER