Healthcare Provider Details

I. General information

NPI: 1508878539
Provider Name (Legal Business Name): RICKI JOSEPH GERLACH CPHT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 JOHN R ST OUTPATIENT PHARMACY 118CP
DETROIT MI
48201-1916
US

IV. Provider business mailing address

16426 MANCHESTER AVE
EASTPOINTE MI
48021-1128
US

V. Phone/Fax

Practice location:
  • Phone: 313-576-4616
  • Fax: 313-576-1105
Mailing address:
  • Phone: 586-306-7198
  • Fax: 313-576-1105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number1401-0452-0763-960
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: