Basic Information
| Provider Information | |||||||||
| NPI: | 1245375336 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SSAC, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | ARCADIA RX PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26777 CENTRAL PARK BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480764162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483527530 | ||||||||
| FaxNumber: | 2483525189 | ||||||||
| Practice Location | |||||||||
| Address1: | 3524 PARK PLAZA RD | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420018900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704424579 | ||||||||
| FaxNumber: | 8007852177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 10/13/2008 | ||||||||
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| AuthorizedOfficialLastName: | SPARLING | ||||||||
| AuthorizedOfficialFirstName: | CATHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP ADMINISTRATIVE SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 2483527530 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ARCADIA PRODUCTS, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 54006077 | 05 | KY | MEDICAID |