Provider Demographics
NPI:1548438724
Name:PINE KNOB PHARMACY #2
Entity type:Organization
Organization Name:PINE KNOB PHARMACY #2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:PLAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:248-625-1215
Mailing Address - Street 1:5625 WATER TOWER PL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-2671
Mailing Address - Country:US
Mailing Address - Phone:248-625-1215
Mailing Address - Fax:
Practice Address - Street 1:5625 WATER TOWER PL
Practice Address - Street 2:SUITE 101
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2671
Practice Address - Country:US
Practice Address - Phone:248-625-1215
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies