Healthcare Provider Details

I. General information

NPI: 1447365473
Provider Name (Legal Business Name): DDM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 12/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 CHUMS VILLAGE DR STE A
TRAVERSE CITY MI
49684-6992
US

IV. Provider business mailing address

4025 CHURNS VILLAGE DR. STE A.
TRAVERSE CITY MI
49684
US

V. Phone/Fax

Practice location:
  • Phone: 231-943-0085
  • Fax: 231-943-0095
Mailing address:
  • Phone: 231-943-0085
  • Fax: 231-943-0095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number5301007598
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. DALE B MAUPIN
Title or Position: PHARMACIST/OWNER
Credential: RPH
Phone: 231-943-0085