Provider Demographics
NPI:1215106034
Name:MEDISERV INC
Entity type:Organization
Organization Name:MEDISERV INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:DORHOUT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:616-340-8780
Mailing Address - Street 1:125 S CHERRY ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-2018
Mailing Address - Country:US
Mailing Address - Phone:810-659-8868
Mailing Address - Fax:810-659-6789
Practice Address - Street 1:125 S CHERRY ST
Practice Address - Street 2:SUITE C
Practice Address - City:FLUSHING
Practice Address - State:MI
Practice Address - Zip Code:48433-2018
Practice Address - Country:US
Practice Address - Phone:810-659-8868
Practice Address - Fax:810-659-6789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301008816291U00000X, 332B00000X, 333600000X, 3336C0004X, 3336L0003X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No291U00000XLaboratoriesClinical Medical Laboratory
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5301008816OtherPHARMACY
MI5315034738OtherCONTROLLED SUBST-PHARMACY