Healthcare Provider Details

I. General information

NPI: 1083518500
Provider Name (Legal Business Name): WALLED LAKE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1336 S COMMERCE RD
WALLED LAKE MI
48390-3010
US

IV. Provider business mailing address

1336 S COMMERCE RD
WALLED LAKE MI
48390-3010
US

V. Phone/Fax

Practice location:
  • Phone: 248-574-5552
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ABDULLAH MUSSAD
Title or Position: GM
Credential:
Phone: 248-574-5552