Healthcare Provider Details

I. General information

NPI: 1013926971
Provider Name (Legal Business Name): DENNIS GERARD VANDECANDELAERE R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 JOHN R
DETROIT MI
48201
US

IV. Provider business mailing address

5103 KENSINGTON
DETRIOT MI
48224
US

V. Phone/Fax

Practice location:
  • Phone: 313-576-3762
  • Fax: 313-576-1105
Mailing address:
  • Phone: 313-576-3762
  • Fax: 313-576-1105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302025771
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: