Provider Demographics
NPI:1316281140
Name:GLORY PHARMACY- JOSEPH CAMPAU LLC
Entity type:Organization
Organization Name:GLORY PHARMACY- JOSEPH CAMPAU LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIEF PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MURSALA
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMED
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:313-871-2020
Mailing Address - Street 1:2385 NORTHWESTERN HWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075
Mailing Address - Country:US
Mailing Address - Phone:248-663-3380
Mailing Address - Fax:248-223-1060
Practice Address - Street 1:9023 JOSEPH CAMPAU ST
Practice Address - Street 2:
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48212-3726
Practice Address - Country:US
Practice Address - Phone:313-871-2020
Practice Address - Fax:313-871-2028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-16
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010099393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2137624OtherPK
MI1316281140Medicaid