1306383005 NPI number — KING CARE PHARMACY LLC

Table of content: (NPI 1306383005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306383005 NPI number — KING CARE PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KING CARE PHARMACY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
YOUR PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306383005
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
713 N WAVERLY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48917-2242
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-253-7512
Provider Business Mailing Address Fax Number:
517-253-7514

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
713 N WAVERLY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48917-2242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-253-7512
Provider Business Practice Location Address Fax Number:
517-253-7514
Provider Enumeration Date:
01/20/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MAGHSOODI
Authorized Official First Name:
MASOOD
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PHARMACIST
Authorized Official Telephone Number:
517-614-1207

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  5301011091 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1306383005 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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