MEDICARE: VILLAGE PHARMACY COMPOUNDING INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0004X	Compounding Pharmacy
3	3336C0003X	Community/Retail Pharmacy	5301010728	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2149862	OTHER		PK

General Provider Information

NPI Number	:	1114317393
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VILLAGE PHARMACY COMPOUNDING INC

Provider Business Mailing Address
First Line	:	3592 WEST MAPLE RD.
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48301
Country	:	US
Telephone Number	:	248-644-6337
Fax Number	:	248-644-1027

Provider Business Practice Location Address
First Line	:	3592 W MAPLE RD
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48301-3371
Country	:	US
Telephone Number	:	248-644-6337
Fax Number	:	248-644-1027

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GABE ZAWAIDEH
Credential	:	RPH
Telephone Number	:	248-644-6337

Provider Enumeration Date	:	01/27/2015
Last Update Date	:	07/19/2018

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