Basic Information
Provider Information | |||||||||
NPI: | 1295918274 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ISIDRO II INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UNIVERSITY PHARMACY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 871819 | ||||||||
Address2: |   | ||||||||
City: | CANTON | ||||||||
State: | MI | ||||||||
PostalCode: | 481877519 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7348129129 | ||||||||
FaxNumber: | 7346291717 | ||||||||
Practice Location | |||||||||
Address1: | 7288 N SHELDON RD STE A | ||||||||
Address2: |   | ||||||||
City: | CANTON | ||||||||
State: | MI | ||||||||
PostalCode: | 481872150 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7348129129 | ||||||||
FaxNumber: | 7346291717 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/12/2007 | ||||||||
LastUpdateDate: | 07/22/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | YOUNG | ||||||||
AuthorizedOfficialFirstName: | MARIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER, PRES, PIC | ||||||||
AuthorizedOfficialTelephone: | 7348129129 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | RPH | ||||||||
NPICertificationDate: | 07/22/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 333600000X |   |   | N |   | Suppliers | Pharmacy |   | 3336C0002X |   |   | N |   | Suppliers | Pharmacy | Clinic Pharmacy | 3336C0003X | 5301008406 | MI | N |   | Suppliers | Pharmacy | Community/Retail Pharmacy | 261QH0100X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
ID Information
ID | Type | State | Issuer | Description | 0P60030 | 01 | MI | MASS IMMUNIZATION | OTHER | 1982884318 | 05 | MI |   | MEDICAID | 2043557 | 01 |   | PK | OTHER | 0P57520 | 01 | MI | PTAN | OTHER | 1295918274 | 05 | MI |   | MEDICAID |