Healthcare Provider Details

I. General information

NPI: 1033749395
Provider Name (Legal Business Name): ORCHARD TRAILS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2020
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23133 ORCHARD LAKE RD STE 101
FARMINGTON MI
48336-3278
US

IV. Provider business mailing address

23133 ORCHARD LAKE RD STE 101
FARMINGTON MI
48336-3278
US

V. Phone/Fax

Practice location:
  • Phone: 248-516-3566
  • Fax: 248-516-3564
Mailing address:
  • Phone: 248-516-3566
  • Fax: 248-516-3564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: STAVROS TRIANT
Title or Position: MEMBER
Credential:
Phone: 248-516-3566