Basic Information
| Provider Information | |||||||||
| NPI: | 1457815565 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ISIDRO II INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | UNIVERSITY PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| 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: | 01/23/2019 | ||||||||
| LastUpdateDate: | 06/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | YOUNG | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | CHRISTINA | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7348129129 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ISIDRO II, INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | N | Ambulatory Health Care Facilities | Clinic/Center | Health Service | 174H00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Health Educator |
ID Information
| ID | Type | State | Issuer | Description | 0P60030 | 01 | MI | PTAN | OTHER | 200810 | 01 | DSME/ DPP | OTHER | 1295918274 | 05 | MI | MEDICAID | 0P57520 | 01 | MI | MASS IMMUNIZATION | OTHER | 1740306778 | 01 | MI | RPH NPI | OTHER |