MEDICARE: PORT HURON 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	:	1629341102
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORT HURON PHARMACY, LLC

Provider Business Mailing Address
First Line	:	515 10TH ST
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-4404
Country	:	US
Telephone Number	:	810-989-5990
Fax Number	:	810-989-5992

Provider Business Practice Location Address
First Line	:	515 10TH ST
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-4404
Country	:	US
Telephone Number	:	810-989-5990
Fax Number	:	810-989-5992

Authorized Official
Title or Position	:	OWNER
Name	:	MR. ANKUR PATEL
Credential	:
Telephone Number	:	248-632-8182

Provider Enumeration Date	:	02/15/2012
Last Update Date	:	02/15/2012

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