Provider Demographics
NPI:1083990345
Name:DIFAZIO, DAVID MARK (PHARMD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MARK
Last Name:DIFAZIO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33333 6 MILE RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-3265
Mailing Address - Country:US
Mailing Address - Phone:734-513-5078
Mailing Address - Fax:734-513-5102
Practice Address - Street 1:33333 6 MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-3265
Practice Address - Country:US
Practice Address - Phone:734-513-5078
Practice Address - Fax:734-513-5102
Is Sole Proprietor?:No
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025677183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist