Provider Demographics
NPI:1962764506
Name:BUCKLEYS PHARMACY OF HAZEL PARK LLC
Entity type:Organization
Organization Name:BUCKLEYS PHARMACY OF HAZEL PARK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMDMPHMBAMS
Authorized Official - Phone:313-971-5030
Mailing Address - Street 1:20721 DEQUINDRE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:HAZEL PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48030-2633
Mailing Address - Country:US
Mailing Address - Phone:248-808-6505
Mailing Address - Fax:248-808-6351
Practice Address - Street 1:20721 DEQUINDRE RD STE B
Practice Address - Street 2:
Practice Address - City:HAZEL PARK
Practice Address - State:MI
Practice Address - Zip Code:48030-2633
Practice Address - Country:US
Practice Address - Phone:248-808-6505
Practice Address - Fax:248-808-6351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-11
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010098403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2376867Medicaid
2135482OtherPK