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General NPI Number Information
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NPI Number | 1164692356
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Entity Type | Organization
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Legal Business Name | GREAT LAKES MEDICAL PHARMACY LLC
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Dates
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Enumeration Date | 03/04/2008
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Last Update Date | 07/05/2016
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Provider Practice Location Address
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Address Line | 23247 PINEWOOD ST STE 100
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City | WARREN
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State | MI
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Zip | 48091-4754
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Country | US
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Telephone | 954-381-7146
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Fax | 877-448-0633
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Provider Business Mailing Address
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Address Line | 23247 PINEWOOD ST STE 100
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City | WARREN
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State | MI
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Zip | 48091-4754
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Country | US
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Telephone | 866-576-5040
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Fax | 877-448-0633
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Authorized Official
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Title or Position | PHARMACIST-IN-CHARGE
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Name | RAMI LAZEKI
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Credential |
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Telephone | 305-455-3836
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 5301010234
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License Number State | MI
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