Provider Demographics
NPI:1992257208
Name:DISCOUNT RX-PORT HURON LLC
Entity type:Organization
Organization Name:DISCOUNT RX-PORT HURON LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KHAJA
Authorized Official - Middle Name:AF
Authorized Official - Last Name:MOHAMMED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-423-4433
Mailing Address - Street 1:4 N ORTONVILLE RD STE B
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48462-8693
Mailing Address - Country:US
Mailing Address - Phone:248-831-1222
Mailing Address - Fax:888-821-2293
Practice Address - Street 1:4 N ORTONVILLE RD STE B
Practice Address - Street 2:
Practice Address - City:ORTONVILLE
Practice Address - State:MI
Practice Address - Zip Code:48462-8693
Practice Address - Country:US
Practice Address - Phone:248-831-1222
Practice Address - Fax:888-821-2293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-03
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010110213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166058OtherPK
MI2382682Medicaid