=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881135309
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREFERRED CARE RX LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2017
-----------------------------------------------------
Last Update Date | 03/16/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16921 W WARREN AVE
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48228-3504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-671-2411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16921 W WARREN AVE
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48228-3504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-671-2411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ALI MOHAMMAD NASERDEAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-671-2411
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------