1104059526 NPI number — PCD CORP

Table of content: (NPI 1104059526)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104059526 NPI number — PCD CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PCD 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:
1104059526
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
C/O CHRISTOPHER PENCAK PC
Provider Second Line Business Mailing Address:
27322 23 MILE RD, STE 7
Provider Business Mailing Address City Name:
CHESTERFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-598-4650
Provider Business Mailing Address Fax Number:
586-598-4651

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20770 GREENFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK PARK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48237-3018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-548-8985
Provider Business Practice Location Address Fax Number:
248-548-9935
Provider Enumeration Date:
09/02/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PENCAK
Authorized Official First Name:
DEREK
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-548-9935

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  5301009146 , 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)

  • Identifier: 2373239 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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