Provider Demographics
NPI:1285177493
Name:BACON, OPAL M (PHARMD)
Entity type:Individual
Prefix:
First Name:OPAL
Middle Name:M
Last Name:BACON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2065 ANITA AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1427
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 FORD PLACE, 1C
Practice Address - Street 2:OUTPATIENT PSYCHIATRY
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-556-7882
Practice Address - Fax:313-874-6650
Is Sole Proprietor?:No
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020447531835P1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1300XPharmacy Service ProvidersPharmacistPsychiatric