MEDICARE: GREAT LAKES RX SAV MOR PHARMACY

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	5301008773	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2370702	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1982888947
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES RX SAV MOR PHARMACY

Provider Business Mailing Address
First Line	:	1770 FORT ST
Second Line	:
City	:	LINCOLN PARK
State	:	MI
Zip	:	48146-1904
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1770 FORT ST
Second Line	:
City	:	LINCOLN PARK
State	:	MI
Zip	:	48146-1904
Country	:	US
Telephone Number	:	313-827-9999
Fax Number	:	313-827-0999

Authorized Official
Title or Position	:	OWNER
Name	:	WAEL KHANAFER
Credential	:
Telephone Number	:	133-412-4622

Provider Enumeration Date	:	12/26/2007
Last Update Date	:	05/08/2009

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