Healthcare Provider Details

I. General information

NPI: 1972938140
Provider Name (Legal Business Name): SPECTRA MED INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2013
Last Update Date: 09/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3160 HAGGERTY RD STE H
WEST BLOOMFIELD MI
48323-2000
US

IV. Provider business mailing address

3160 HAGGERTY RD STE H
WEST BLOOMFIELD MI
48323-2000
US

V. Phone/Fax

Practice location:
  • Phone: 248-669-5757
  • Fax: 248-669-2090
Mailing address:
  • Phone: 248-669-5757
  • Fax: 248-669-2090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301010104
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number5301010104
License Number StateMI

VIII. Authorized Official

Name: MR. DANIEL STAYER
Title or Position: PRESIDENT/PHARMACIST
Credential: R.PH.
Phone: 248-669-5757