Healthcare Provider Details

I. General information

NPI: 1558021931
Provider Name (Legal Business Name): BRONSON VILLAGE DRUG, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2021
Last Update Date: 12/27/2021
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 E DELAWARE ST
DECATUR MI
49045-1151
US

IV. Provider business mailing address

25344 RED ARROW HWY
MATTAWAN MI
49071-9742
US

V. Phone/Fax

Practice location:
  • Phone: 269-423-6770
  • Fax:
Mailing address:
  • Phone: 269-655-4402
  • Fax:

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: DR. JEFFREY ROBERT STULL
Title or Position: OWNER
Credential: PHARM.D.
Phone: 269-655-4402