Provider Demographics
NPI:1164534236
Name:VG'S PHARMACY INC
Entity Type:Organization
Organization Name:VG'S PHARMACY INC
Other - Org Name:VG'S PHARMACY #4
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY PRODUCT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRYON
Authorized Official - Middle Name:C
Authorized Official - Last Name:HIGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:810-629-1383
Mailing Address - Street 1:4165 E COURT ST
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-1717
Mailing Address - Country:US
Mailing Address - Phone:810-742-8326
Mailing Address - Fax:810-742-3900
Practice Address - Street 1:4165 E COURT ST
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1717
Practice Address - Country:US
Practice Address - Phone:810-742-8326
Practice Address - Fax:810-742-3900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301005242183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2345850OtherNABP/NCPDP
MI4074862Medicaid
MI4074862Medicaid