MEDICARE: PREMIER HOME PHARMACY OF MI

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	5301010075	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2137422	OTHER		PK

General Provider Information

NPI Number	:	1831441971
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER HOME PHARMACY OF MI

Provider Business Mailing Address
First Line	:	23874 KEAN ST
Second Line	:	SUITE 120
City	:	DEARBORN
State	:	MI
Zip	:	48124-1804
Country	:	US
Telephone Number	:	313-887-9111
Fax Number	:	313-887-4229

Provider Business Practice Location Address
First Line	:	23874 KEAN ST
Second Line	:	SUITE 120
City	:	DEARBORN
State	:	MI
Zip	:	48124-1804
Country	:	US
Telephone Number	:	313-887-9111
Fax Number	:	313-887-4229

Authorized Official
Title or Position	:	OWNER
Name	:	SYED RAZA
Credential	:
Telephone Number	:	734-658-8985

Provider Enumeration Date	:	10/13/2012
Last Update Date	:	03/02/2016

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Directions to “PREMIER HOME PHARMACY OF MI ” Practice Location

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