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General NPI Number Information
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NPI Number | 1023160371
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Entity Type | Organization
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Legal Business Name | SLBTJ
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Dates
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Enumeration Date | 01/17/2007
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Last Update Date | 09/12/2007
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Provider Practice Location Address
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Address Line | 16101 MACK AVE
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City | DETROIT
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State | MI
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Zip | 48224-3644
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Country | US
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Telephone | 313-881-3188
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Fax | 313-881-3128
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Provider Business Mailing Address
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Address Line | 16101 MACK AVE
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City | DETROIT
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State | MI
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Zip | 48224-3644
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CHARLENE WILLIAMS
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Credential |
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Telephone | 313-881-3188
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 5315028304
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License Number State | MI
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