=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083027908
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIET AID
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2014
-----------------------------------------------------
Last Update Date | 06/09/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2255 S JACKSON RD
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-780-9536
-----------------------------------------------------
Fax | 517-782-9140
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2255 S JACKSON RD
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49201-8344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-780-9536
-----------------------------------------------------
Fax | 517-782-9140
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST
-----------------------------------------------------
Name | MR. GARY MICHAEL BRION
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 517-745-8026
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 5302023467
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------