Provider Demographics
NPI:1043482243
Name:MOTOR CITY PHARMACY CORP
Entity type:Organization
Organization Name:MOTOR CITY PHARMACY CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHARMACIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUZAN
Authorized Official - Middle Name:BERRY
Authorized Official - Last Name:FADLALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:313-838-2555
Mailing Address - Street 1:20526 PLYMOUTH RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-1201
Mailing Address - Country:US
Mailing Address - Phone:313-838-2555
Mailing Address - Fax:313-838-1320
Practice Address - Street 1:20526 PLYMOUTH RD
Practice Address - Street 2:SUITE D
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-1201
Practice Address - Country:US
Practice Address - Phone:313-838-2555
Practice Address - Fax:313-838-1320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010051133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1981639Medicaid
MI0988300001Medicare NSC