Healthcare Provider Details

I. General information

NPI: 1700922291
Provider Name (Legal Business Name): MICHAEL DENNIS THIBAULT B.S. R.PH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82 MAPLETON RD
GROSSE POINTE FARMS MI
48236-3615
US

IV. Provider business mailing address

82 MAPLETON RD
GROSSE POINTE FARMS MI
48236-3615
US

V. Phone/Fax

Practice location:
  • Phone: 313-885-5679
  • Fax: 313-885-5679
Mailing address:
  • Phone: 313-885-5679
  • Fax: 313-885-5679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302024848
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: