MEDICARE: BUCKLEYS EASTSIDE 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	3336C0002X	Clinic Pharmacy
3	3336C0004X	Compounding Pharmacy
4	3336C0003X	Community/Retail Pharmacy	5301010311	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2144115	OTHER		PK

General Provider Information

NPI Number	:	1922421528
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BUCKLEYS EASTSIDE PHARMACY LLC

Provider Business Mailing Address
First Line	:	15014 E 8 MILE RD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48205-1352
Country	:	US
Telephone Number	:	313-245-0300
Fax Number	:	313-245-0330

Provider Business Practice Location Address
First Line	:	15014 E 8 MILE RD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48205-1352
Country	:	US
Telephone Number	:	313-245-0300
Fax Number	:	313-245-0330

Authorized Official
Title or Position	:	DIRECTOR OF CLINICAL SERVICES
Name	:	ANTHONY COLE
Credential	:
Telephone Number	:	313-971-5030

Provider Enumeration Date	:	02/03/2014
Last Update Date	:	02/03/2014

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