Provider Demographics
NPI:1144524034
Name:SHELBY CREEK PHARMACY LLC
Entity type:Organization
Organization Name:SHELBY CREEK PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KASSEM
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLEIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-232-4275
Mailing Address - Street 1:8180 26 MILE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-5129
Mailing Address - Country:US
Mailing Address - Phone:586-232-4275
Mailing Address - Fax:586-232-4296
Practice Address - Street 1:8180 26 MILE RD STE 103
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-5129
Practice Address - Country:US
Practice Address - Phone:586-232-4275
Practice Address - Fax:586-232-4296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-06
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010094623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2374902OtherNCPDP PROVIDER IDENTIFICATION NUMBER