Healthcare Provider Details

I. General information

NPI: 1487907960
Provider Name (Legal Business Name): GREAT AMERICAN ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2012
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29355 NORTHWESTERN HWY STE 220
SOUTHFIELD MI
48034-1053
US

IV. Provider business mailing address

29355 NORTHWESTERN HWY STE 220
SOUTHFIELD MI
48034-1051
US

V. Phone/Fax

Practice location:
  • Phone: 248-799-3900
  • Fax: 248-799-3992
Mailing address:
  • Phone: 248-799-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301009932
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number5301009932
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number5301009932
License Number StateMI

VIII. Authorized Official

Name: DR. TONY JOHN KOKKATT
Title or Position: PRESIDENT
Credential: PHARM D
Phone: 248-799-3900