Healthcare Provider Details

I. General information

NPI: 1952681090
Provider Name (Legal Business Name): MR. THOMAS DAVID DODGE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2011
Last Update Date: 08/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15242 N HOLLY RD
HOLLY MI
48442-1141
US

IV. Provider business mailing address

15242 N HOLLY RD
HOLLY MI
48442-1141
US

V. Phone/Fax

Practice location:
  • Phone: 248-634-2314
  • Fax: 248-634-0998
Mailing address:
  • Phone: 248-634-2314
  • Fax: 248-634-0998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302020473
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: