MEDICARE: HURON RIVER 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	5301009771	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2376336	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1548530041
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HURON RIVER PHARMACY LLC

Provider Business Mailing Address
First Line	:	19162 HURON RIVER DR
Second Line	:
City	:	NEW BOSTON
State	:	MI
Zip	:	48164-9727
Country	:	US
Telephone Number	:	734-753-2000
Fax Number	:	734-753-2002

Provider Business Practice Location Address
First Line	:	19162 HURON RIVER DR
Second Line	:
City	:	NEW BOSTON
State	:	MI
Zip	:	48164-9727
Country	:	US
Telephone Number	:	734-753-2000
Fax Number	:	734-753-2002

Authorized Official
Title or Position	:	OWNER/PIC
Name	:	AHMAD MOHAMAD-ALI
Credential	:	RPH
Telephone Number	:	313-300-4221

Provider Enumeration Date	:	12/31/2011
Last Update Date	:	05/09/2012

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