Healthcare Provider Details

I. General information

NPI: 1548530041
Provider Name (Legal Business Name): HURON RIVER PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2011
Last Update Date: 05/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19162 HURON RIVER DR
NEW BOSTON MI
48164-9727
US

IV. Provider business mailing address

19162 HURON RIVER DR
NEW BOSTON MI
48164-9727
US

V. Phone/Fax

Practice location:
  • Phone: 734-753-2000
  • Fax: 734-753-2002
Mailing address:
  • Phone: 734-753-2000
  • Fax: 734-753-2002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301009771
License Number StateMI

VIII. Authorized Official

Name: AHMAD MOHAMAD-ALI
Title or Position: OWNER/PIC
Credential: RPH
Phone: 313-300-4221