Healthcare Provider Details

I. General information

NPI: 1437107448
Provider Name (Legal Business Name): PROFESSIONAL VILLAGE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 COLE RD STE B
MONROE MI
48162-4104
US

IV. Provider business mailing address

128 COLE RD STE B
MONROE MI
48162-4104
US

V. Phone/Fax

Practice location:
  • Phone: 734-457-2211
  • Fax: 734-457-3738
Mailing address:
  • Phone: 734-457-2211
  • Fax: 734-457-3738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number5301006995
License Number StateMI

VIII. Authorized Official

Name: JOHN BICKING
Title or Position: OWNER
Credential: RPH
Phone: 734-243-5656