Healthcare Provider Details

I. General information

NPI: 1194395939
Provider Name (Legal Business Name): BETSY C VARGHESE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25996 GRATIOT AVE
ROSEVILLE MI
48066-4436
US

IV. Provider business mailing address

25996 GRATIOT AVE
ROSEVILLE MI
48066-4436
US

V. Phone/Fax

Practice location:
  • Phone: 586-774-1070
  • Fax: 586-774-6987
Mailing address:
  • Phone: 586-774-1070
  • Fax: 586-774-6987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5303007358
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: