Healthcare Provider Details

I. General information

NPI: 1710091418
Provider Name (Legal Business Name): MR. TIMOTHY J MIODEK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21000 E 12 MILE RD SUITE 124
SAINT CLAIR SHORES MI
48081-1116
US

IV. Provider business mailing address

12853 CORBIN DR
STERLING HTS MI
48313-3311
US

V. Phone/Fax

Practice location:
  • Phone: 586-447-5030
  • Fax:
Mailing address:
  • Phone: 586-254-9551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302030353
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: