Provider Demographics
NPI:1699340539
Name:BRONSON VILLAGE DRUG, INC.
Entity type:Organization
Organization Name:BRONSON VILLAGE DRUG, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:STULL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:269-668-1449
Mailing Address - Street 1:25344 RED ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:MATTAWAN
Mailing Address - State:MI
Mailing Address - Zip Code:49071-9742
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25344 RED ARROW HWY
Practice Address - Street 2:
Practice Address - City:MATTAWAN
Practice Address - State:MI
Practice Address - Zip Code:49071-9742
Practice Address - Country:US
Practice Address - Phone:269-668-1449
Practice Address - Fax:888-498-1343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5315226820OtherSTATE OF MICHIGAN PHARMACY LICENSE
MI5315226820OtherSTATE OF MICHIGAN PHARMACY LICENSE