Provider Demographics
NPI:1407903560
Name:HIGHLAND ROAD PLAZA LLC
Entity type:Organization
Organization Name:HIGHLAND ROAD PLAZA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GEBRE
Authorized Official - Middle Name:
Authorized Official - Last Name:ASHEBIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-274-1037
Mailing Address - Street 1:6479 WYNDHAM DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-1070
Mailing Address - Country:US
Mailing Address - Phone:517-458-2261
Mailing Address - Fax:517-458-7758
Practice Address - Street 1:213 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MORENCI
Practice Address - State:MI
Practice Address - Zip Code:49256-1420
Practice Address - Country:US
Practice Address - Phone:517-458-2261
Practice Address - Fax:517-458-7758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010012913336C0003X, 3336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2334794OtherOTHER ID NUMBER
MIMI3179OtherPTAN
MIMI3179OtherPTAN