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General NPI Number Information
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NPI Number | 1891803268
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Entity Type | Organization
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Legal Business Name | PINE KNOB PHARMACY #3, INC.
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Dates
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Enumeration Date | 08/27/2006
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Last Update Date | 10/27/2016
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Provider Practice Location Address
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Address Line | 6770 DIXIE HIGHWAY SUITE 201
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City | CLARKSTON
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State | MI
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Zip | 48346
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Country | US
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Telephone | 248-620-3588
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Fax | 248-620-0037
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Provider Business Mailing Address
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Address Line | 6770 DIXIE HIGHWAY SUITE 201
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City | CLARKSTON
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State | MI
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Zip | 48346
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Country | US
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Telephone | 248-620-3588
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Fax | 248-620-0037
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. RAY ALEXANDER BULLARD
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Credential | R.PH.
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Telephone | 248-620-3588
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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 | 5301006232
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License Number State | MI
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