Basic Information
Provider Information | |||||||||
NPI: | 1861121576 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ISIDRO II, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
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: | 06/08/2022 | ||||||||
LastUpdateDate: | 06/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | YOUNG | ||||||||
AuthorizedOfficialFirstName: | MARIA | ||||||||
AuthorizedOfficialMiddleName: | CHRISTINA | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7348129129 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | BS PHARM | ||||||||
NPICertificationDate: | 06/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X |   |   | Y |   | Suppliers | Pharmacy |   |
ID Information
ID | Type | State | Issuer | Description | 5301012844 | 01 | MI | PHARMACY LICENSE | OTHER | 23D1083577 | 01 |   | CLIA | OTHER |