=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386885903
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2009
-----------------------------------------------------
Last Update Date | 06/12/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21225 KELLY RD STE. #1
-----------------------------------------------------
City | EASTPOINTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48021-3100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-778-8612
-----------------------------------------------------
Fax | 586-778-8615
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21225 KELLY RD STE. #1
-----------------------------------------------------
City | EASTPOINTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48021-3100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LIZA EKOLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-268-0953
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 5301009110
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------