Healthcare Provider Details

I. General information

NPI: 1700271350
Provider Name (Legal Business Name): MILLER ROAD PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2015
Last Update Date: 04/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5097 MILLER RD
FLINT MI
48507-1043
US

IV. Provider business mailing address

5097 MILLER RD
FLINT MI
48507-1043
US

V. Phone/Fax

Practice location:
  • Phone: 810-228-3304
  • Fax: 810-228-3307
Mailing address:
  • Phone: 810-228-3304
  • Fax: 810-228-3307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301010651
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number5301010651
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number5301010651
License Number StateMI

VIII. Authorized Official

Name: DR. ABUSUFIAN ELTAIB ELTAHIR
Title or Position: PHARMACY MANAGER
Credential: PHARMD
Phone: 810-228-3304