Healthcare Provider Details

I. General information

NPI: 1306164140
Provider Name (Legal Business Name): KOACH3 INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2010
Last Update Date: 06/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9600 DEXTER AVE
DETROIT MI
48206-1816
US

IV. Provider business mailing address

9600 DEXTER AVE
DETROIT MI
48206-1816
US

V. Phone/Fax

Practice location:
  • Phone: 313-870-9201
  • Fax: 313-870-9207
Mailing address:
  • Phone: 313-870-9201
  • Fax: 313-870-9207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301009312
License Number StateMI

VIII. Authorized Official

Name: KOMAL ACHARYA
Title or Position: PRESIDENT
Credential:
Phone: 313-870-9201