=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891313755
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HIGHLAND PARK OAK STREET PHARMACY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2020
-----------------------------------------------------
Last Update Date | 08/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14529 WOODWARD AVE
-----------------------------------------------------
City | HIGHLAND PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48203-2905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-485-2971
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14529 WOODWARD AVE
-----------------------------------------------------
City | HIGHLAND PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48203-2905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST
-----------------------------------------------------
Name | FOUAD OMAR
-----------------------------------------------------
Credential | PHARM.D.
-----------------------------------------------------
Telephone | 313-485-2971
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------