Provider Demographics
NPI:1679569362
Name:CLARKSTONRX LLC
Entity type:Organization
Organization Name:CLARKSTONRX LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:D
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-625-8030
Mailing Address - Street 1:5838 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-2963
Mailing Address - Country:US
Mailing Address - Phone:248-625-8030
Mailing Address - Fax:248-625-9207
Practice Address - Street 1:5838 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2963
Practice Address - Country:US
Practice Address - Phone:248-625-8030
Practice Address - Fax:248-625-9207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-27
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2327496Medicaid
0N54000OtherMEDICARE PART B
4180030001Medicare NSC