MEDICARE: MR. DIMITRIOS BASTOUNIS RPH

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	183500000X	Pharmacist	5302029638	MI

General Provider Information

NPI Number	:	1760649339
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DIMITRIOS BASTOUNIS RPH

Provider Business Mailing Address
First Line	:	17370 SHINNECOCK DR
Second Line	:
City	:	MACOMB
State	:	MI
Zip	:	48042-1147
Country	:	US
Telephone Number	:	586-764-5983
Fax Number	:

Provider Business Practice Location Address
First Line	:	7887 26 MILE RD
Second Line	:
City	:	WASHINGTON TWP
State	:	MI
Zip	:	48094-3820
Country	:	US
Telephone Number	:	586-677-3438
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2008
Last Update Date	:	05/20/2008

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