=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013344910
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLETH DISCOUNT PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2013
-----------------------------------------------------
Last Update Date | 10/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7635 E 8 MILE RD SUITE 4
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48091-2946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-383-9043
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7635 E 8 MILE RD SUITE 4
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48091-2946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-383-9043
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | FLEVIAN CHUKWUDI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 734-383-9043
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 5301010191
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------