Provider Demographics
NPI:1851831036
Name:QUALICARE RX, LLC
Entity type:Organization
Organization Name:QUALICARE RX, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:
Authorized Official - Last Name:TANANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-469-2931
Mailing Address - Street 1:28370 JOY RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-4133
Mailing Address - Country:US
Mailing Address - Phone:734-469-2930
Mailing Address - Fax:734-469-2929
Practice Address - Street 1:28370 JOY RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-4133
Practice Address - Country:US
Practice Address - Phone:734-469-2930
Practice Address - Fax:734-469-2929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-07
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336S0011X
MI53010111103336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2168098OtherPK
MI1851831036Medicaid