Provider Demographics
NPI:1730209743
Name:NOTTTINGHAM PHARMACY LLC
Entity type:Organization
Organization Name:NOTTTINGHAM PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VIRENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAIDHANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-885-3363
Mailing Address - Street 1:15800 E WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-3218
Mailing Address - Country:US
Mailing Address - Phone:313-885-3363
Mailing Address - Fax:313-885-3357
Practice Address - Street 1:15800 E WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-3218
Practice Address - Country:US
Practice Address - Phone:313-885-3363
Practice Address - Fax:313-885-3357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-31
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010059563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1730209743OtherPK
MI2352184Medicaid
MI1730209743Medicaid