Healthcare Provider Details

I. General information

NPI: 1306340955
Provider Name (Legal Business Name): PRESTIGE SPECIALTY PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 03/17/2023
Certification Date: 03/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3739 15 MILE RD
STERLING HEIGHTS MI
48310
US

IV. Provider business mailing address

3739 15 MILE RD
STERLING HEIGHTS MI
48310
US

V. Phone/Fax

Practice location:
  • Phone: 877-742-7621
  • Fax: 586-883-9388
Mailing address:
  • Phone: 877-742-7621
  • Fax: 586-883-9388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number StateMI

VIII. Authorized Official

Name: PAUL CYPRUS
Title or Position: MEMBER
Credential:
Phone: 313-289-7878