Provider Demographics
NPI:1548441124
Name:BELLEVILLE NEIGHBORHOOD PHARMACY
Entity type:Organization
Organization Name:BELLEVILLE NEIGHBORHOOD PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANG
Authorized Official - Prefix:
Authorized Official - First Name:TAMEKA
Authorized Official - Middle Name:
Authorized Official - Last Name:BACON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-649-0762
Mailing Address - Street 1:887 SUMPTER RD
Mailing Address - Street 2:STE A
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-4905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:887 SUMPTER RD
Practice Address - Street 2:STE A
Practice Address - City:BELLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48111-4905
Practice Address - Country:US
Practice Address - Phone:734-699-7904
Practice Address - Fax:734-699-7914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-24
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010087443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2370485OtherOTHER ID NUMBER