Basic Information
| Provider Information | |||||||||
| NPI: | 1063521581 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PERRY DRUG STORES INC AND SUBSIDIARIES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RITE AID PHARMACY 04334 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 NEWBERRY COMMONS | ||||||||
| Address2: | |||||||||
| City: | ETTERS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173199363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177612633 | ||||||||
| FaxNumber: | 7179758659 | ||||||||
| Practice Location | |||||||||
| Address1: | 19016 FORT ST | ||||||||
| Address2: | RIVERVIEW COMMONS | ||||||||
| City: | RIVERVIEW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481936701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344792010 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 01/13/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ZOREK | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR MANAGER PROVIDER ENROLLMENT AND | ||||||||
| AuthorizedOfficialTelephone: | 7179755937 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | 3067 | MI | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2308511 | 05 | MI | MEDICAID | 2308511 | 01 | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER |