Healthcare Provider Details

I. General information

NPI: 1861882599
Provider Name (Legal Business Name): BUCKLEYS PHARMACY OF WARREN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2015
Last Update Date: 04/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29200 RYAN RD
WARREN MI
48092-4242
US

IV. Provider business mailing address

29200 RYAN RD
WARREN MI
48092-4242
US

V. Phone/Fax

Practice location:
  • Phone: 586-558-8787
  • Fax: 586-558-8793
Mailing address:
  • Phone: 586-558-8787
  • Fax: 586-558-8793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301010625
License Number StateMI

VIII. Authorized Official

Name: ANTHONY COLE
Title or Position: DIRECTOR OF CLINICAL SERVICES
Credential: PHARMDMPHMBAMS
Phone: 586-558-8787