=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013652163
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREAT LAKES LTC PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2022
-----------------------------------------------------
Last Update Date | 04/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4260 MONROE ST
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43606-1944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-890-4748
-----------------------------------------------------
Fax | 419-890-4822
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4260 MONROE ST
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43606-1944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-982-3220
-----------------------------------------------------
Fax | 313-982-3221
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST/OWNER
-----------------------------------------------------
Name | HASSAN ISMAIL
-----------------------------------------------------
Credential | R.PH
-----------------------------------------------------
Telephone | 419-890-4748
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------