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NPI Code Detail

MEDICARE: CORKTOWN PHARMACY LLC

MEDICARE: CORKTOWN PHARMACY LLC
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
13336C0003XCommunity/Retail Pharmacy
2333600000XPharmacy

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12164664OTHERPK

General Provider Information

NPI Number : 1508316605
Entity Type Code : Organization
Provider Name (Legal Business Name) : CORKTOWN PHARMACY LLC
Provider Business Mailing Address
First Line : 23487 HILL ST
Second Line :
City : DEARBORN HEIGHTS
State : MI
Zip : 48127-2382
Country : US
Telephone Number : 313-414-7170
Fax Number :
Provider Business Practice Location Address
First Line : 1726 HOWARD ST
Second Line : SUITE 200
City : DETROIT
State : MI
Zip : 48216-1921
Country : US
Telephone Number : 313-414-7170
Fax Number :
Authorized Official
Title or Position : MEMBER
Name : EMAD SALEH
Credential :
Telephone Number : 313-414-7170
Provider Enumeration Date : 10/12/2016
Last Update Date : 10/14/2016

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Directions to “CORKTOWN PHARMACY LLC ” Practice Location

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