Healthcare Provider Details

I. General information

NPI: 1356760730
Provider Name (Legal Business Name): MAPLE PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2014
Last Update Date: 11/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5829 W MAPLE RD STE 129
WEST BLOOMFIELD MI
48322-2294
US

IV. Provider business mailing address

5773 MILL POND CT
WEST BLOOMFIELD MI
48322-2078
US

V. Phone/Fax

Practice location:
  • Phone: 248-757-2503
  • Fax: 248-757-2847
Mailing address:
  • Phone: 248-342-0314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number5301010400
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number5301010400
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301010400
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number5301010400
License Number StateMI

VIII. Authorized Official

Name: HENGAMEH KHALEDI
Title or Position: PRESIDENT
Credential:
Phone: 248-757-2503