Provider Demographics
NPI:1285833806
Name:VG'S PHARMACY, INC
Entity Type:Organization
Organization Name:VG'S PHARMACY, INC
Other - Org Name:VG'S PHARMACY #15
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 1:209 S ALLOY DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3401
Mailing Address - Country:US
Mailing Address - Phone:810-629-1383
Mailing Address - Fax:810-750-1599
Practice Address - Street 1:1390 N LEROY ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2762
Practice Address - Country:US
Practice Address - Phone:810-629-6074
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010086663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5195165Medicaid
2370055OtherNABP