Healthcare Provider Details

I. General information

NPI: 1932617404
Provider Name (Legal Business Name): MR. CARTER HENDRICKS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2018
Last Update Date: 01/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18341 US HIGHWAY 41
LANSE MI
49946-8024
US

IV. Provider business mailing address

13446 SUNSET DR
LANSE MI
49946-8370
US

V. Phone/Fax

Practice location:
  • Phone: 906-524-6202
  • Fax:
Mailing address:
  • Phone: 906-201-2522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302044063
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: