=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235411133
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHIL JOSEPH DEMEULENAERE III RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2011
-----------------------------------------------------
Last Update Date | 03/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1710 W JOHN BEERS RD
-----------------------------------------------------
City | STEVENSVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49127-9409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-429-1153
-----------------------------------------------------
Fax | 269-429-1495
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3391 CEDAR LN
-----------------------------------------------------
City | BRIDGMAN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49106-9739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-465-9203
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 26019560A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 5302030476
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------