EASTBORN RX PHARMACY LLC (EASTBORN RX PHARMACY) - NPI NUMBER 1396091518

Summary

Provider Name: EASTBORN RX PHARMACY LLC (EASTBORN RX PHARMACY)

NPI Number: 1396091518

Clasification: Pharmacy (3336C0003X)

Specialization: Community/Retail Pharmacy

Address:
7526 WYOMING ST
SUITE 1
DEARBORN, MI
ZIP 48126

Phone Number: (313) 491-1010



Detailed Information

EASTBORN RX PHARMACY LLC is a community/retail pharmacy pharmacy in Dearborn, MI. The provider is a pharmacy where pharmacists store, prepare, and dispense medicinal preparations and/or prescriptions for a local patient population in accordance with federal and state law; counsel patients and caregivers (sometimes independent of the dispensing process); administer vaccinations; and provide other professional services associated with pharmaceutical care such as health screenings, consultative services with other health care providers, collaborative practice, disease state management, and education classes. The assigned NPI number for this provider is 1396091518 and is registered as an organization entity type.
The provider Is Doing Business As Eastborn Rx Pharmacy.

The provider's business address is:

7526 WYOMING ST
SUITE 1
DEARBORN, MI
ZIP 48126-690
Phone: (313) 491-1010
Fax: (313) 491-2020

The provider's authorized official is Ali Cheaito .
The authorized official title is Owner and has the following contact phone number (313) 491-1010.

The enumeration date for this NPI number is 7/25/2012 and was last updated on 12/21/2012.

Map - Location of Practice

Taxonomy Codes

The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1 3336C0003X Pharmacy Community/Retail Pharmacy 5301009915 MI Yes

Other (Legacy) Identifiers

The following legacy identifiers are available for this provider:

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
1 2377198 OTHER NCPDP PROVIDER IDENTIFICATION NUMBER

NPI Record

No. Field Name Field Value Field Definition 1
1 NPI 1396091518 The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
2 Entity Type Code 2 Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
3 Employer Identification Number EIN The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
4 Provider Organization Name Legal Business Name EASTBORN RX PHARMACY LLC The name of the organization provider. If the provider is an organization, this is the legal business name.
5 Provider Other Organization Name EASTBORN RX PHARMACY Other name by which the organization provider is or has been known.
6 Provider Other Organization Name Type Code 3 Code identifying the type of other name. Codes are: 1 = former name; 2 = professional name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other.
7 Provider First Line Business Practice Location Address 7526 WYOMING ST The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
8 Provider Second Line Business Practice Location Address SUITE 1 The second line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
9 Provider Business Practice Location Address City Name DEARBORN The city name in the location address of the provider being identified.
10 Provider Business Practice Location Address State Name MI The State code in the location of the provider being identified.
11 Provider Business Practice Location Address Postal Code 481261690 The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
12 Provider Business Practice Location Address Country Code If outside U S US The country code in the location address of the provider being identified.
13 Provider Business Practice Location Address Telephone Number 3134911010 The telephone number associated with the location address of the provider being identified.
14 Provider Business Practice Location Address Fax Number 3134912020 The fax number associated with the location address of the provider being identified.
15 Provider Enumeration Date 7/25/2012 The date the provider was assigned a unique identifier (assigned an NPI).
16 Last Update Date 12/21/2012 The date that a record was last updated or changed.
17 Authorized Official Last Name CHEAITO The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
18 Authorized Official First Name ALI The first name of the authorized official.
19 Authorized Official Title or Position OWNER The title or position of the authorized official.
20 Authorized Official Telephone Number 3134911010 The 10-position telephone number of the authorized official.
21 Healthcare Provider Taxonomy Code 1 3336C0003X Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
22 Provider License Number 1 5301009915 The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’.
23 Provider License Number State Code 1 MI The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number.
24 Healthcare Provider Primary Taxonomy Switch 1 Y
25 Other Provider Identifier 1 2377198 Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
26 Other Provider Identifier Type Code 1 01 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
27 Other Provider Identifier Issuer 1 NCPDP PROVIDER IDENTIFICATION NUMBER
28 Is Organization Subpart N
29 Authorized Official Credential Text PHARM. D

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This page was last updated on: 4/19/2015

(1) Field Definition Source-. Federal Register / Vol. 69, No. 15 / Friday, January 23, 2004 / Rules and Regulations - Part II Department of Health and Human Services Office of the Secretary 45 CFR Part 162 HIPAA Administrative Simplification: Standard Unique Health Identifier for Health Care Providers; Final Rule

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