Provider Demographics
NPI:1306137864
Name:DEROSSI S PHARMACY LLC
Entity type:Organization
Organization Name:DEROSSI S PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SACHIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-246-8800
Mailing Address - Street 1:15348 FORT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-1304
Mailing Address - Country:US
Mailing Address - Phone:734-246-8800
Mailing Address - Fax:734-246-8808
Practice Address - Street 1:15348 FORT ST
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-1304
Practice Address - Country:US
Practice Address - Phone:734-246-8800
Practice Address - Fax:734-246-8808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-02
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010095693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2375497OtherNCPDP PROVIDER IDENTIFICATION NUMBER