MEDICARE: PARK MED 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	3336C0003X	Community/Retail Pharmacy	5301011302	MI

General Provider Information

NPI Number	:	1396253696
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARK MED PHARMACY LLC

Provider Business Mailing Address
First Line	:	45361 OAK FOREST DR
Second Line	:
City	:	NORTHVILLE
State	:	MI
Zip	:	48168-4440
Country	:	US
Telephone Number	:	313-443-1781
Fax Number	:	313-521-4010

Provider Business Practice Location Address
First Line	:	15200 GRATIOT AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48205-1327
Country	:	US
Telephone Number	:	313-521-4000
Fax Number	:	313-521-4010

Authorized Official
Title or Position	:	PHARMACIST/OWNER
Name	:	DR. AUDAY MAKI
Credential	:	RPH, PH.D
Telephone Number	:	313-443-1781

Provider Enumeration Date	:	01/21/2018
Last Update Date	:	01/21/2018

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Directions to “PARK MED PHARMACY LLC ” Practice Location

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