Healthcare Provider Details

I. General information

NPI: 1346358710
Provider Name (Legal Business Name): SDS PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2006
Last Update Date: 03/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 N MAIN STREET
CAPAC MI
48014
US

IV. Provider business mailing address

43155 W 9 MILE RD
NOVI MI
48375-4190
US

V. Phone/Fax

Practice location:
  • Phone: 810-395-2336
  • Fax: 810-395-9015
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301006496
License Number StateMI

VIII. Authorized Official

Name: MR. SCOT DOUGLAS SHELDON
Title or Position: PRESIDENT
Credential:
Phone: 810-387-4244