MEDICARE: CONANT PLAZA 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	5301007843	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

General Provider Information

NPI Number	:	1437202587
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONANT PLAZA PHARMACY LLC

Provider Business Mailing Address
First Line	:	3611 CARPENTER ST
Second Line	:	SUITE #3
City	:	DETROIT
State	:	MI
Zip	:	48212-2784
Country	:	US
Telephone Number	:	313-366-1221
Fax Number	:	313-366-2947

Provider Business Practice Location Address
First Line	:	3611 CARPENTER ST
Second Line	:	SUITE #3
City	:	DETROIT
State	:	MI
Zip	:	48212-2784
Country	:	US
Telephone Number	:	313-366-1221
Fax Number	:	313-366-2947

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. SAMIR A BERRI
Credential	:	RPH
Telephone Number	:	313-366-1221

Provider Enumeration Date	:	01/20/2007
Last Update Date	:	10/09/2013

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