1386753507 NPI number — DIX DRUGS STORE CORP

Table of content: MICHAEL GREGORY MICHALIK MD (NPI 1790306306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386753507 NPI number — DIX DRUGS STORE CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIX DRUGS STORE CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386753507
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
655 GOLFCREST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEARBORN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-843-2400
Provider Business Mailing Address Fax Number:
313-843-2402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10066 DIX
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEARBORN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48120-1551
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-843-2400
Provider Business Practice Location Address Fax Number:
313-843-2402
Provider Enumeration Date:
08/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FADLALLAH
Authorized Official First Name:
HASSANE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST AND OWNER
Authorized Official Telephone Number:
313-843-2400

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  5301006503 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 5301006503 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)