Provider Demographics
NPI:1174651442
Name:HENDRICKS, CARL
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:HENDRICKS
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 1:753 GLENEAGLES
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48357-4778
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:620 N PONTIAC TRL
Practice Address - Street 2:
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390-3443
Practice Address - Country:US
Practice Address - Phone:248-669-2776
Practice Address - Fax:248-669-2835
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302026119183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist