=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063502011
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VALLEY MEDICAL PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2006
-----------------------------------------------------
Last Update Date | 03/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | G5142 MILLER RD
-----------------------------------------------------
City | FLINT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-230-8252
-----------------------------------------------------
Fax | 810-230-8215
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | G5142 MILLER RD
-----------------------------------------------------
City | FLINT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-230-8252
-----------------------------------------------------
Fax | 810-230-8215
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CHAWKI FAKIH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 810-230-8252
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 5315016378
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------