Organization
GREAT LAKES PHARMACY LLC
Active
Other names
Great Lakes Pharmacy LLC
Organization subpart
No
Provider details
NPI number
Authorized official
ANIRUDDHA PATHAK RPH (MGR,PIC, AO)
(443) 783-5539
Entity
Organization
Contact information
Practice address
3247 BIDDLE AVE STE A, WYANDOTTE, MI 48192-5951
(734) 224-6400
(734) 224-6500
Mailing address
3247 BIDDLE AVE STE A, WYANDOTTE, MI 48192-5951
(734) 224-6400
(734) 224-6500
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
5301011109
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2167778
PK
—
Enumeration date
02/13/2017
Last updated
04/20/2017
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