Healthcare Provider Details

I. General information

NPI: 1093823460
Provider Name (Legal Business Name): GREAT LAKES PHARMACIES I INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2006
Last Update Date: 04/22/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6213 CHICAGO RD SUITE 200
WARREN MI
48092
US

IV. Provider business mailing address

6213 CHICAGO RD. SUITE 200
WARREN MI
48092
US

V. Phone/Fax

Practice location:
  • Phone: 586-751-7979
  • Fax: 586-751-0809
Mailing address:
  • Phone: 586-751-7979
  • Fax: 586-751-0809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301004106
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number5301004106
License Number StateMI

VIII. Authorized Official

Name: ROBERT HARB
Title or Position: OWNER/RPH
Credential: RPH
Phone: 248-867-1683