Provider Demographics
NPI:1104260066
Name:ST. CLAIR SHORE PHARMACY MI LLC
Entity type:Organization
Organization Name:ST. CLAIR SHORE PHARMACY MI LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HEMA
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-304-2221
Mailing Address - Street 1:25014 LITTLE MACK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080
Mailing Address - Country:US
Mailing Address - Phone:586-359-6517
Mailing Address - Fax:586-359-6523
Practice Address - Street 1:25014 LITTLE MACK AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080
Practice Address - Country:US
Practice Address - Phone:586-359-6517
Practice Address - Fax:586-359-6523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-23
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MI53150593143336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140011OtherPK