Provider Demographics
NPI:1861882599
Name:BUCKLEYS PHARMACY OF WARREN LLC
Entity type:Organization
Organization Name:BUCKLEYS PHARMACY OF WARREN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINICAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMDMPHMBAMS
Authorized Official - Phone:586-558-8787
Mailing Address - Street 1:29200 RYAN RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-4242
Mailing Address - Country:US
Mailing Address - Phone:586-558-8787
Mailing Address - Fax:586-558-8793
Practice Address - Street 1:29200 RYAN RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-4242
Practice Address - Country:US
Practice Address - Phone:586-558-8787
Practice Address - Fax:586-558-8793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-03
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010106253336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2150063OtherPK
MI2365600Medicaid