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General NPI Number Information
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NPI Number | 1922421528
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Entity Type | Organization
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Legal Business Name | BUCKLEYS EASTSIDE PHARMACY LLC
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Dates
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Enumeration Date | 02/03/2014
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Last Update Date | 02/03/2014
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Provider Practice Location Address
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Address Line | 15014 E 8 MILE RD
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City | DETROIT
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State | MI
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Zip | 48205-1352
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Country | US
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Telephone | 313-245-0300
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Fax | 313-245-0330
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Provider Business Mailing Address
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Address Line | 15014 E 8 MILE RD
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City | DETROIT
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State | MI
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Zip | 48205-1352
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Country | US
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Telephone | 313-245-0300
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Fax | 313-245-0330
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Authorized Official
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Title or Position | DIRECTOR OF CLINICAL SERVICES
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Name | ANTHONY COLE
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Credential |
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Telephone | 313-971-5030
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0002X
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Taxonomy Name | Clinic Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding Pharmacy
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 5301010311
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License Number State | MI
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