MEDICARE: GREAT LAKES SAV-RITE

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	3336C0003X	Community/Retail Pharmacy	5301009398	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2374471	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1881909869
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES SAV-RITE

Provider Business Mailing Address
First Line	:	1770 FORT ST
Second Line	:
City	:	LINCOLN PARK
State	:	MI
Zip	:	48146-1904
Country	:	US
Telephone Number	:	313-827-9999
Fax Number	:	313-827-0999

Provider Business Practice Location Address
First Line	:	1770 FORT ST
Second Line	:
City	:	LINCOLN PARK
State	:	MI
Zip	:	48146-1904
Country	:	US
Telephone Number	:	313-827-9999
Fax Number	:	313-827-0999

Authorized Official
Title or Position	:	OWNER
Name	:	OUSSAMA ABDOU
Credential	:
Telephone Number	:	313-827-9999

Provider Enumeration Date	:	08/13/2010
Last Update Date	:	10/21/2010

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Directions to “GREAT LAKES SAV-RITE ” Practice Location

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