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General NPI Number Information
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NPI Number | 1396253696
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Entity Type | Organization
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Legal Business Name | PARK MED PHARMACY LLC
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Dates
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Enumeration Date | 01/21/2018
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Last Update Date | 01/21/2018
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Provider Practice Location Address
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Address Line | 15200 GRATIOT AVE
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City | DETROIT
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State | MI
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Zip | 48205-1327
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Country | US
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Telephone | 313-521-4000
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Fax | 313-521-4010
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Provider Business Mailing Address
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Address Line | 45361 OAK FOREST DR
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City | NORTHVILLE
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State | MI
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Zip | 48168-4440
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Country | US
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Telephone | 313-443-1781
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Fax | 313-521-4010
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Authorized Official
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Title or Position | PHARMACIST/OWNER
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Name | DR. AUDAY MAKI
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Credential | RPH, PH.D
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Telephone | 313-443-1781
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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 | 5301011302
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License Number State | MI
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