MEDICARE: DALCOMA SPECIALTY 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	3336C0004X	Compounding Pharmacy
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	5301010422	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2145053	OTHER		PK

General Provider Information

NPI Number	:	1578989489
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DALCOMA SPECIALTY PHARMACY LLC

Provider Business Mailing Address
First Line	:	43337 SCHOENHERR RD
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48313-1959
Country	:	US
Telephone Number	:	586-697-3877
Fax Number	:	586-697-3878

Provider Business Practice Location Address
First Line	:	43337 SCHOENHERR RD
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48313-1959
Country	:	US
Telephone Number	:	586-697-3877
Fax Number	:	586-697-3878

Authorized Official
Title or Position	:	OWNER
Name	:	HIMAL SHAH
Credential	:
Telephone Number	:	248-566-0116

Provider Enumeration Date	:	03/16/2014
Last Update Date	:	05/06/2019

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