Provider Demographics
NPI:1982922779
Name:VAN BUREN PHARMACY LLC
Entity Type:Organization
Organization Name:VAN BUREN PHARMACY LLC
Other - Org Name:VAN BUREN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:P.I.C.
Authorized Official - Prefix:
Authorized Official - First Name:SAMEERAH
Authorized Official - Middle Name:
Authorized Official - Last Name:CORTEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:734-325-6318
Mailing Address - Street 1:11650 BELLEVILLE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-3380
Mailing Address - Country:US
Mailing Address - Phone:734-325-6318
Mailing Address - Fax:734-325-1007
Practice Address - Street 1:11650 BELLEVILLE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:BELLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48111-3380
Practice Address - Country:US
Practice Address - Phone:734-325-6318
Practice Address - Fax:734-325-1007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-04
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010101963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1982922779Medicaid
2125315OtherPK