Provider Demographics
NPI:1992813364
Name:22835 VAN DYKE DRUGS INC
Entity type:Organization
Organization Name:22835 VAN DYKE DRUGS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:
Authorized Official - Last Name:TUBBEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-757-6505
Mailing Address - Street 1:22835 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-2356
Mailing Address - Country:US
Mailing Address - Phone:586-757-6505
Mailing Address - Fax:586-757-7785
Practice Address - Street 1:22835 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-2356
Practice Address - Country:US
Practice Address - Phone:586-757-6505
Practice Address - Fax:586-757-7785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-27
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010109853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2164020OtherPK
2347979OtherOTHER ID NUMBER
MI2347979Medicaid