Healthcare Provider Details

I. General information

NPI: 1134750144
Provider Name (Legal Business Name): STEVEN DALE PRYOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2020
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15255 17 MILE RD
CLINTON TOWNSHIP MI
48038-5718
US

IV. Provider business mailing address

15255 17 MILE RD
CLINTON TOWNSHIP MI
48038-5718
US

V. Phone/Fax

Practice location:
  • Phone: 586-412-6755
  • Fax:
Mailing address:
  • Phone: 586-412-6755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5315145137
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: