=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316616287
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REGINALD BEBRI
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2021
-----------------------------------------------------
Last Update Date | 09/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1950 W CENTRE AVE
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49024-5334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-321-0664
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 PATRICIA PLACE DR
-----------------------------------------------------
City | WESTLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48185-3828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-776-6084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 5302413720
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------