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General NPI Number Information
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NPI Number | 1255449625
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Entity Type | Organization
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Legal Business Name | PINE KNOB PHARMACY 4 INC
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Dates
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Enumeration Date | 08/27/2006
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Last Update Date | 04/15/2008
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Provider Practice Location Address
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Address Line | 5710 BELLA ROSA BLVD
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City | CLARKSTON
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State | MI
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Zip | 48348-4773
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Country | US
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Telephone | 248-620-0296
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Fax | 248-674-7436
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Provider Business Mailing Address
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Address Line | 43155 W 9 MILE RD
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City | NOVI
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State | MI
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Zip | 48375-4190
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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 | MANAGER PHARMACY SERVICES
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Name | STEPHEN GRAHAM
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Credential |
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Telephone | 248-348-1570
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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 | 5301006722
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License Number State | MI
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