Healthcare Provider Details

I. General information

NPI: 1487566279
Provider Name (Legal Business Name): REVIVA COMPOUNDING PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1664 FORT ST
LINCOLN PARK MI
48146-1909
US

IV. Provider business mailing address

1664 FORT ST
LINCOLN PARK MI
48146-1909
US

V. Phone/Fax

Practice location:
  • Phone: 313-384-0484
  • Fax:
Mailing address:
  • Phone: 313-384-0484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. MARY BEYDOUN
Title or Position: OWNER/PHARMACIST IN CHARGE
Credential: PHARMD
Phone: 313-701-2261