Healthcare Provider Details

I. General information

NPI: 1790226843
Provider Name (Legal Business Name): RED CAP PHARMACY 002, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2017
Last Update Date: 03/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 S WESTERN AVE STE F
CHICAGO IL
60608-3816
US

IV. Provider business mailing address

37484 INTERCHANGE DR
FARMINGTON HILLS MI
48335-1023
US

V. Phone/Fax

Practice location:
  • Phone: 313-737-0691
  • Fax: 313-286-0220
Mailing address:
  • Phone: 313-737-0691
  • Fax: 313-286-0220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number054.020246
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MIKE SHEHADI
Title or Position: CEO
Credential:
Phone: 313-737-0691