Healthcare Provider Details

I. General information

NPI: 1316616287
Provider Name (Legal Business Name): REGINALD BEBRI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2021
Last Update Date: 09/13/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 W CENTRE AVE
PORTAGE MI
49024-5334
US

IV. Provider business mailing address

801 PATRICIA PLACE DR
WESTLAND MI
48185-3828
US

V. Phone/Fax

Practice location:
  • Phone: 269-321-0664
  • Fax:
Mailing address:
  • Phone: 734-776-6084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number5302413720
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: