Provider Demographics
NPI:1699007542
Name:ROSEDALE COMMUNITY PHARMACY INC
Entity type:Organization
Organization Name:ROSEDALE COMMUNITY PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ZAINAB
Authorized Official - Middle Name:
Authorized Official - Last Name:JAAFAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-262-4600
Mailing Address - Street 1:PO BOX 532258
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48153-2258
Mailing Address - Country:US
Mailing Address - Phone:313-531-0100
Mailing Address - Fax:313-531-0101
Practice Address - Street 1:19220 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-1707
Practice Address - Country:US
Practice Address - Phone:313-531-0100
Practice Address - Fax:313-531-0101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-03
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MI53010092963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1699007542Medicaid
2123723OtherPK