Provider Demographics
NPI:1114193554
Name:MAC, ANDREW J (RPH)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:J
Last Name:MAC
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32320 5 MILE RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-6109
Mailing Address - Country:US
Mailing Address - Phone:734-353-7809
Mailing Address - Fax:888-722-5579
Practice Address - Street 1:34550 GLENDALE ST
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-1304
Practice Address - Country:US
Practice Address - Phone:734-377-3154
Practice Address - Fax:734-345-3525
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-06
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302028280183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302028280OtherMICHIGAN CONTROLLED SUBSTANCE LICENSE
MI5302028280OtherMICHIGAN PHARMACIST LICENSE