Healthcare Provider Details

I. General information

NPI: 1326588294
Provider Name (Legal Business Name): LAKEWOOD FAMILY PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2017
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17000 EXECUTIVE PLAZA DR STE 209
DEARBORN MI
48126-2793
US

IV. Provider business mailing address

17000 EXECUTIVE PLAZA DR STE 209
DEARBORN MI
48126-2793
US

V. Phone/Fax

Practice location:
  • Phone: 313-982-3770
  • Fax: 313-982-3771
Mailing address:
  • Phone: 313-982-3770
  • Fax: 313-982-3771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301011107
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: HASSAN ISMAIL
Title or Position: OWNER
Credential: B.S PHARMACY
Phone: 313-982-3770