Basic Information
| Provider Information | |||||||||
| NPI: | 1710492673 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PANDYA | ||||||||
| FirstName: | SANTOSH | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | PHARMACIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6300 COMMERCE DR | ||||||||
| Address2: | |||||||||
| City: | WESTLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481859120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347284030 | ||||||||
| FaxNumber: | 7347284037 | ||||||||
| Practice Location | |||||||||
| Address1: | 16311 GRAND RIVER AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482271825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138381100 | ||||||||
| FaxNumber: | 3138381103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2017 | ||||||||
| LastUpdateDate: | 01/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 5302036078 | MI | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 1649404526 | 05 | MI | MEDICAID | 1902143118 | 05 | MI | MEDICAID |