Provider Demographics
NPI:1437692779
Name:MD ROYAL PHARMACY INC
Entity type:Organization
Organization Name:MD ROYAL PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:DAKDOUK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, PHARM D
Authorized Official - Phone:734-288-3588
Mailing Address - Street 1:12866 FORT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-1060
Mailing Address - Country:US
Mailing Address - Phone:734-288-3588
Mailing Address - Fax:734-288-3610
Practice Address - Street 1:12866 FORT ST
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-1060
Practice Address - Country:US
Practice Address - Phone:734-288-3588
Practice Address - Fax:734-288-3610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-18
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MI53010110613336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5301011061Medicaid
2166371OtherPK