Healthcare Provider Details

I. General information

NPI: 1831441971
Provider Name (Legal Business Name): PREMIER HOME PHARMACY OF MI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2012
Last Update Date: 03/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23874 KEAN ST SUITE 120
DEARBORN MI
48124-1804
US

IV. Provider business mailing address

23874 KEAN ST SUITE 120
DEARBORN MI
48124-1804
US

V. Phone/Fax

Practice location:
  • Phone: 313-887-9111
  • Fax: 313-887-4229
Mailing address:
  • Phone: 313-887-9111
  • Fax: 313-887-4229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301010075
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SYED RAZA
Title or Position: OWNER
Credential:
Phone: 734-658-8985