Healthcare Provider Details

I. General information

NPI: 1598620734
Provider Name (Legal Business Name): DOMINO MED PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5770 PLYMOUTH RD
ANN ARBOR MI
48105-9312
US

IV. Provider business mailing address

5770 PLYMOUTH RD
ANN ARBOR MI
48105-9312
US

V. Phone/Fax

Practice location:
  • Phone: 734-669-1560
  • Fax: 734-669-1570
Mailing address:
  • Phone: 734-669-1560
  • Fax: 734-669-1570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JOHN TRAVIS
Title or Position: PHARMACIST
Credential:
Phone: 313-303-5084