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General NPI Number Information
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NPI Number | 1568366946
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Entity Type | Organization
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Legal Business Name | MARYSVILLE FAMILY PHARMACY LLC
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Dates
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Enumeration Date | 10/07/2026
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Last Update Date | 10/07/2026
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Provider Practice Location Address
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Address Line | 1750 GRATIOT BLVD
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City | MARYSVILLE
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State | MI
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Zip | 48040-1182
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Country | US
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Telephone | 313-778-1013
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Fax |
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Provider Business Mailing Address
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Address Line | 1750 GRATIOT BLVD
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City | MARYSVILLE
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State | MI
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Zip | 48040-1182
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PIC
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Name | JASON TLAIS
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Credential |
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Telephone | 313-778-1013
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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 |
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License Number State | NULL
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