Provider Demographics
NPI:1316290729
Name:DEARBORN FAMILY PHARMACY LLC
Entity type:Organization
Organization Name:DEARBORN FAMILY PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AIMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ABUEIDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-523-5334
Mailing Address - Street 1:17000 EXECUTIVE PLAZA DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2610
Mailing Address - Country:US
Mailing Address - Phone:313-982-3770
Mailing Address - Fax:313-982-3771
Practice Address - Street 1:17000 EXECUTIVE PLAZA DR
Practice Address - Street 2:SUITE 104
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2610
Practice Address - Country:US
Practice Address - Phone:313-982-3770
Practice Address - Fax:313-982-3771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-23
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 332B00000X, 3336L0003X
MI53010098793336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2377237OtherNCPDP PROVIDER IDENTIFICATION NUMBER