Provider Demographics
NPI:1194171850
Name:PACKARD DISCOUNT PHARMACY LLC
Entity type:Organization
Organization Name:PACKARD DISCOUNT PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:ABDULLA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARIFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-633-9310
Mailing Address - Street 1:4726 GREENFIELD RD STE 101
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-4124
Mailing Address - Country:US
Mailing Address - Phone:313-633-9310
Mailing Address - Fax:313-633-9706
Practice Address - Street 1:4726 GREENFIELD RD STE 101
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-4124
Practice Address - Country:US
Practice Address - Phone:313-633-9310
Practice Address - Fax:313-633-9706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-11
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010109363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2160247OtherPK
MI1194171850Medicaid