MEDICARE: DEARBORN FAMILY PHARMACY LLC

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	3336C0003X	Community/Retail Pharmacy	5301009879	MI
3	332B00000X	Durable Medical Equipment & Medical Supplies
4	3336L0003X	Long Term Care Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2377237	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1316290729
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEARBORN FAMILY PHARMACY LLC

Provider Business Mailing Address
First Line	:	17000 EXECUTIVE PLAZA DR
Second Line	:	SUITE 104
City	:	DEARBORN
State	:	MI
Zip	:	48126-2610
Country	:	US
Telephone Number	:	313-982-3770
Fax Number	:	313-982-3771

Provider Business Practice Location Address
First Line	:	17000 EXECUTIVE PLAZA DR
Second Line	:	SUITE 104
City	:	DEARBORN
State	:	MI
Zip	:	48126-2610
Country	:	US
Telephone Number	:	313-982-3770
Fax Number	:	313-982-3771

Authorized Official
Title or Position	:	OWNER
Name	:	AIMAN ABUEIDA
Credential	:
Telephone Number	:	313-523-5334

Provider Enumeration Date	:	10/23/2012
Last Update Date	:	09/22/2014

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