Healthcare Provider Details

I. General information

NPI: 1063520435
Provider Name (Legal Business Name): PINE KNOB PHARMACY 5 INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2006
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10740 DIXIE HWY
DAVISBURG MI
48350-1123
US

IV. Provider business mailing address

43155 W 9 MILE RD
NOVI MI
48375-4190
US

V. Phone/Fax

Practice location:
  • Phone: 248-620-5222
  • Fax: 248-625-0314
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301007729
License Number StateMI

VIII. Authorized Official

Name: STEPHEN GRAHAM
Title or Position: MANAGER PHARMACY SERVICES
Credential:
Phone: 248-348-1570