Provider Demographics
NPI:1700271350
Name:MILLER ROAD PHARMACY
Entity type:Organization
Organization Name:MILLER ROAD PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ABUSUFIAN
Authorized Official - Middle Name:ELTAIB
Authorized Official - Last Name:ELTAHIR
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:810-228-3304
Mailing Address - Street 1:5097 MILLER RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-1043
Mailing Address - Country:US
Mailing Address - Phone:810-228-3304
Mailing Address - Fax:810-228-3307
Practice Address - Street 1:5097 MILLER RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-1043
Practice Address - Country:US
Practice Address - Phone:810-228-3304
Practice Address - Fax:810-228-3307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-31
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010106513336S0011X, 3336L0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy