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General NPI Number Information
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NPI Number | 1427050129
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Entity Type | Organization
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Legal Business Name | WESTSIDE PHARMACY OF DETROIT, INC
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Dates
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Enumeration Date | 08/11/2005
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Last Update Date | 03/03/2009
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Provider Practice Location Address
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Address Line | 10600 W MCNICHOLS RD
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City | DETROIT
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State | MI
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Zip | 48221-2366
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Country | US
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Telephone | 313-342-1555
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Fax | 313-342-2120
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Provider Business Mailing Address
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Address Line | 10600 W MCNICHOLS RD
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City | DETROIT
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State | MI
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Zip | 48221-2366
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Country | US
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Telephone | 313-342-1555
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Fax | 313-342-2120
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. RENARDO GRAY
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Credential | R.PH.
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Telephone | 313-342-1555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | 004296
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License Number State | MI
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