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General NPI Number Information
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NPI Number | 1538440250
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Entity Type | Organization
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Legal Business Name | MISHAWAKA FAMILY PHARMACY LLC
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Dates
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Enumeration Date | 09/08/2011
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Last Update Date | 09/08/2011
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Provider Practice Location Address
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Address Line | 611 E DOUGLAS RD STE 104
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City | MISHAWAKA
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State | IN
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Zip | 46545-1464
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Country | US
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Telephone | 574-340-0388
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Fax |
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Provider Business Mailing Address
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Address Line | 611 E DOUGLAS RD STE 104
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City | MISHAWAKA
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State | IN
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Zip | 46545-1464
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Country | US
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Telephone | 574-340-0388
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Fax |
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Authorized Official
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Title or Position | PHARMACIST
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Name | MR. CHAWKI FAKIH
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Credential | R.PH
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Telephone | 313-443-5959
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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 | 60006269B
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License Number State | IN
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