Basic Information
| Provider Information | |||||||||
| NPI: | 1902174196 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOLARA MEDICAL SUPPLIES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOLARA MEDICAL SUPPLIES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 W GERMANTOWN PIKE STE 250 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH MEETING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194621437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106306357 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 38023 SCHOOLCRAFT RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481501065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885688145 | ||||||||
| FaxNumber: | 8009992514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2011 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | GRIGGS | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4072060040 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | 5301010213 | MI | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2132583 | 01 | PK | OTHER | 1114167111 | 05 | MI | MEDICAID |