MEDICARE: BELLEVILLE NEIGHBORHOOD PHARMACY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	5301008744	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2370485	OTHER		OTHER ID NUMBER

General Provider Information

NPI Number	:	1548441124
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BELLEVILLE NEIGHBORHOOD PHARMACY

Provider Business Mailing Address
First Line	:	887 SUMPTER RD
Second Line	:	STE A
City	:	BELLEVILLE
State	:	MI
Zip	:	48111-4905
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	887 SUMPTER RD
Second Line	:	STE A
City	:	BELLEVILLE
State	:	MI
Zip	:	48111-4905
Country	:	US
Telephone Number	:	734-699-7904
Fax Number	:	734-699-7914

Authorized Official
Title or Position	:	MANG
Name	:	TAMEKA BACON
Credential	:
Telephone Number	:	734-649-0762

Provider Enumeration Date	:	11/24/2007
Last Update Date	:	12/04/2007

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Directions to “BELLEVILLE NEIGHBORHOOD PHARMACY ” Practice Location

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