Healthcare Provider Details

I. General information

NPI: 1982922779
Provider Name (Legal Business Name): VAN BUREN PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2010
Last Update Date: 11/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11650 BELLEVILLE RD SUITE 103
BELLEVILLE MI
48111-3380
US

IV. Provider business mailing address

11650 BELLEVILLE RD SUITE 103
BELLEVILLE MI
48111-3380
US

V. Phone/Fax

Practice location:
  • Phone: 734-325-6318
  • Fax: 734-325-1007
Mailing address:
  • Phone: 734-325-6318
  • Fax: 734-325-1007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301010196
License Number StateMI

VIII. Authorized Official

Name: SAMEERAH CORTEZ
Title or Position: P.I.C.
Credential: RPH
Phone: 734-325-6318