=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316281140
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLORY PHARMACY- JOSEPH CAMPAU LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2012
-----------------------------------------------------
Last Update Date | 11/25/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9023 JOSEPH CAMPAU ST
-----------------------------------------------------
City | HAMTRAMCK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48212-3726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-871-2020
-----------------------------------------------------
Fax | 313-871-2028
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2385 NORTHWESTERN HWY SUITE 200
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-663-3380
-----------------------------------------------------
Fax | 248-223-1060
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CHIEF PHARMACIST
-----------------------------------------------------
Name | MURSALA AHMED
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 313-871-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 5301009939
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------