Provider Demographics
NPI:1003127929
Name:VAHALEK, EDWARD CHARLES
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:CHARLES
Last Name:VAHALEK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25425 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:CENTER LINE
Mailing Address - State:MI
Mailing Address - Zip Code:48015-1825
Mailing Address - Country:US
Mailing Address - Phone:586-757-6179
Mailing Address - Fax:586-757-1004
Practice Address - Street 1:25425 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:CENTER LINE
Practice Address - State:MI
Practice Address - Zip Code:48015-1825
Practice Address - Country:US
Practice Address - Phone:586-757-6179
Practice Address - Fax:586-757-1004
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302024612183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist