Healthcare Provider Details

I. General information

NPI: 1093346942
Provider Name (Legal Business Name): BOGDAN YAVORENKO PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2020
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10915 BELLEVILLE RD
VAN BUREN TWP MI
48111-1386
US

IV. Provider business mailing address

10915 BELLEVILLE RD
VAN BUREN TWP MI
48111-1386
US

V. Phone/Fax

Practice location:
  • Phone: 734-697-4000
  • Fax:
Mailing address:
  • Phone: 734-697-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302038894
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: