Provider Demographics
NPI:1952852857
Name:VALLEY MEDICAL PHARMACY LLC
Entity type:Organization
Organization Name:VALLEY MEDICAL PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:ELKHOZAI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:734-729-2882
Mailing Address - Street 1:7107 N WAYNE RD STE A
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-2172
Mailing Address - Country:US
Mailing Address - Phone:313-433-2390
Mailing Address - Fax:734-729-6546
Practice Address - Street 1:7107 N WAYNE RD STE A
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-2172
Practice Address - Country:US
Practice Address - Phone:734-729-2882
Practice Address - Fax:734-729-6546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2025-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010110023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1952852857Medicaid