Healthcare Provider Details

I. General information

NPI: 1417962028
Provider Name (Legal Business Name): LIVERNOIS EXPRESS PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 01/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15530 PURITAN ST
DETROIT MI
48227-2342
US

IV. Provider business mailing address

15530 PURITAN ST
DETROIT MI
48227-2342
US

V. Phone/Fax

Practice location:
  • Phone: 313-659-1622
  • Fax: 313-659-1621
Mailing address:
  • Phone: 313-659-1622
  • Fax: 313-659-1621

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 Number5301008192
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: C OLIVER DURU
Title or Position: PHARMACIST/OWNER
Credential: RPH
Phone: 313-659-1622