=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336952845
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN IGNACIOUS WIERZBICKI PHARMD, MBA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2025
-----------------------------------------------------
Last Update Date | 01/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3901 BEAUBIEN ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48201-2119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-745-5278
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 46287 SPRUCE DR
-----------------------------------------------------
City | SHELBY TWP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48315-5753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-567-2620
-----------------------------------------------------
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 | 5302414079
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------