MEDICARE: DEARBORN COMMUNITY CARE 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	5301011007	MI

General Provider Information

NPI Number	:	1629527734
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEARBORN COMMUNITY CARE PHARMACY LLC

Provider Business Mailing Address
First Line	:	15120 MICHIGAN AVE
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48126-3768
Country	:	US
Telephone Number	:	313-558-2121
Fax Number	:	313-558-2020

Provider Business Practice Location Address
First Line	:	15120 MICHIGAN AVE
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48126-3768
Country	:	US
Telephone Number	:	313-558-2121
Fax Number	:	313-558-2020

Authorized Official
Title or Position	:	MEMBER
Name	:	NABIL MOHSEN MOHSEN AL-SUBARI
Credential	:	RPH
Telephone Number	:	313-558-2121

Provider Enumeration Date	:	09/30/2016
Last Update Date	:	02/05/2017

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