Provider Demographics
NPI:1619375201
Name:TEL-12 PHARMACY LLC
Entity type:Organization
Organization Name:TEL-12 PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONTY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KAMPOSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-304-7705
Mailing Address - Street 1:22255 GREENFIELD RD
Mailing Address - Street 2:SUITE 530
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3730
Mailing Address - Country:US
Mailing Address - Phone:248-304-7686
Mailing Address - Fax:248-479-8117
Practice Address - Street 1:29201 TELEGRAPH RD STE 230
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-7645
Practice Address - Country:US
Practice Address - Phone:248-304-7705
Practice Address - Fax:248-395-0495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-12
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy