Provider Demographics
NPI:1386959385
Name:SIX MILE PHARMACY LLC
Entity type:Organization
Organization Name:SIX MILE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NAZMIEH
Authorized Official - Middle Name:
Authorized Official - Last Name:JADALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-397-7254
Mailing Address - Street 1:7145 W MCNICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-2664
Mailing Address - Country:US
Mailing Address - Phone:313-397-7254
Mailing Address - Fax:313-397-7048
Practice Address - Street 1:7145 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-2664
Practice Address - Country:US
Practice Address - Phone:313-397-7254
Practice Address - Fax:313-397-7048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-13
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010094013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2374469Medicaid
2374469OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MI6706990001Medicare NSC