MEDICARE: KNIGHT DRUGS EAST SEVEN MILE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy	5301007146	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2360989	OTHER	MI	NCPDP
3	1104819937	OTHER	MI	NPI

General Provider Information

NPI Number	:	1104819937
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KNIGHT DRUGS EAST SEVEN MILE, INC.

Provider Business Mailing Address
First Line	:	2520 INDUSTRIAL ROW DR
Second Line	:
City	:	TROY
State	:	MI
Zip	:	48084-7035
Country	:	US
Telephone Number	:	248-540-8066
Fax Number	:	248-540-0112

Provider Business Practice Location Address
First Line	:	14071 E 7 MILE RD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48205-2335
Country	:	US
Telephone Number	:	313-839-9545
Fax Number	:	313-839-9546

Authorized Official
Title or Position	:	PRESIDENT OF OPERATIONS
Name	:	MR. JOHN DEJONGH
Credential	:
Telephone Number	:	248-540-8066

Provider Enumeration Date	:	08/26/2005
Last Update Date	:	02/12/2009

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