Healthcare Provider Details

I. General information

NPI: 1003295569
Provider Name (Legal Business Name): MI CARE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2015
Last Update Date: 07/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 CHURCH ST
MOUNT CLEMENS MI
48043-2331
US

IV. Provider business mailing address

33 CHURCH ST
MOUNT CLEMENS MI
48043-2331
US

V. Phone/Fax

Practice location:
  • Phone: 586-447-8777
  • Fax: 586-447-8902
Mailing address:
  • Phone: 586-447-8777
  • Fax: 586-447-8902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301010681
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: RENU PATHAK
Title or Position: OWNER,AO
Credential:
Phone: 443-783-5539