Healthcare Provider Details

I. General information

NPI: 1629341102
Provider Name (Legal Business Name): PORT HURON PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2012
Last Update Date: 02/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 10TH ST
PORT HURON MI
48060-4404
US

IV. Provider business mailing address

515 10TH ST
PORT HURON MI
48060-4404
US

V. Phone/Fax

Practice location:
  • Phone: 810-989-5990
  • Fax: 810-989-5992
Mailing address:
  • Phone: 810-989-5990
  • Fax: 810-989-5992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. ANKUR PATEL
Title or Position: OWNER
Credential:
Phone: 248-632-8182