Provider Demographics
NPI:1093823452
Name:SDS PHARMACY INC
Entity Type:Organization
Organization Name:SDS PHARMACY INC
Other - Org Name:SHELDON PHARMACY OF YALE, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOT
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:SHELDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-387-4244
Mailing Address - Street 1:43155 W 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-4190
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 S MAIN ST
Practice Address - Street 2:
Practice Address - City:YALE
Practice Address - State:MI
Practice Address - Zip Code:48097-3317
Practice Address - Country:US
Practice Address - Phone:810-387-4244
Practice Address - Fax:810-387-2605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-27
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010057413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2320923OtherOTHER ID NUMBER
MI2320923Medicaid
2320923OtherOTHER ID NUMBER