Healthcare Provider Details

I. General information

NPI: 1568954014
Provider Name (Legal Business Name): PONTIAC GENERAL HOSPITAL PHARMACY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N PERRY ST STE 100
PONTIAC MI
48342-2217
US

IV. Provider business mailing address

50 N PERRY ST STE 100
PONTIAC MI
48342-2217
US

V. Phone/Fax

Practice location:
  • Phone: 248-859-0020
  • Fax: 248-859-0025
Mailing address:
  • Phone: 248-859-0020
  • Fax: 248-859-0025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number5301011400
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301011400
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number5301011400
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number5301011400
License Number StateMI

VIII. Authorized Official

Name: MANSOOR KHAN
Title or Position: PHARMACIST-IN-CHARGE/OWNER
Credential: PHARM. D.
Phone: 586-596-4198