Healthcare Provider Details

I. General information

NPI: 1801991757
Provider Name (Legal Business Name): INDEPENDENT COMMUNITY PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8742 W WARREN
DEARBORN MI
48126
US

IV. Provider business mailing address

8742 W WARREN
DEARBORN MI
48126
US

V. Phone/Fax

Practice location:
  • Phone: 313-931-2133
  • Fax: 313-931-3509
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number5301003741
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: VICTOR KOBLIN
Title or Position: PRESIDENT
Credential: RPH
Phone: 318-931-2133