Provider Demographics
NPI:1548712979
Name:EXECUTIVE INFUSION SERVICES LLC
Entity type:Organization
Organization Name:EXECUTIVE INFUSION SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER / CLINICAL PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:AIMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ABUEIDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-982-3220
Mailing Address - Street 1:17000 EXECUTIVE PLAZA DR
Mailing Address - Street 2:SUITE 201 - B
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2793
Mailing Address - Country:US
Mailing Address - Phone:313-982-3221
Mailing Address - Fax:313-982-3221
Practice Address - Street 1:12821 D-13 S. SAQINAW ST
Practice Address - Street 2:
Practice Address - City:GRAND BLANK
Practice Address - State:MI
Practice Address - Zip Code:48439
Practice Address - Country:US
Practice Address - Phone:313-982-3220
Practice Address - Fax:313-982-3221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-02
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336H0001X
MI53010100963336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2165926OtherPK