=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356760730
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAPLE PHARMACY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2014
-----------------------------------------------------
Last Update Date | 11/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5829 W MAPLE RD STE 129
-----------------------------------------------------
City | WEST BLOOMFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48322-2294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-757-2503
-----------------------------------------------------
Fax | 248-757-2847
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5773 MILL POND CT
-----------------------------------------------------
City | WEST BLOOMFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48322-2078
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-342-0314
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | HENGAMEH KHALEDI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-757-2503
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 5301010400
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336S0011X
-----------------------------------------------------
Taxonomy Name | Specialty Pharmacy
-----------------------------------------------------
License Number | 5301010400
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 5301010400
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 5301010400
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------