Provider Demographics
NPI:1902148356
Name:BUCKLEYS PHARMACY OF DETROIT LLC
Entity Type:Organization
Organization Name:BUCKLEYS PHARMACY OF DETROIT LLC
Other - Org Name:BUCKLEY'S PHARMACY #103
Other - Org Type:Doing Business As
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:
Authorized Official - Phone:313-971-5030
Mailing Address - Street 1:14313 GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-2107
Mailing Address - Country:US
Mailing Address - Phone:313-272-0202
Mailing Address - Fax:313-272-0924
Practice Address - Street 1:14313 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-2107
Practice Address - Country:US
Practice Address - Phone:313-272-0202
Practice Address - Fax:313-272-0924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-25
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010100553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2377871OtherNCPDP PROVIDER IDENTIFICATION NUMBER