MEDICARE: SHIAWASSEE 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

General Provider Information

NPI Number	:	1487231635
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHIAWASSEE PHARMACY LLC

Provider Business Mailing Address
First Line	:	23601 W 7 MILE RD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48219-1728
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	23601 W 7 MILE RD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48219-1728
Country	:	US
Telephone Number	:	313-591-1010
Fax Number	:

Authorized Official
Title or Position	:	PIC/CO-OWNER
Name	:	BASHEER ALTAIRI
Credential	:	PHARMD
Telephone Number	:	313-591-1010

Provider Enumeration Date	:	03/25/2021
Last Update Date	:	09/07/2021

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