Healthcare Provider Details

I. General information

NPI: 1457985780
Provider Name (Legal Business Name): MICHAEL ALFRED VANWASSHENOVA PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2020
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 S MONROE ST
MONROE MI
48161-1442
US

IV. Provider business mailing address

919 S MONROE ST
MONROE MI
48161-1442
US

V. Phone/Fax

Practice location:
  • Phone: 734-384-9559
  • Fax: 734-384-5597
Mailing address:
  • Phone: 734-384-9559
  • Fax: 734-384-5597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302032982
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: