Provider Demographics
NPI:1316022502
Name:HADDIX, DONOVAN MATTHEW (RPH)
Entity Type:Individual
Prefix:MR
First Name:DONOVAN
Middle Name:MATTHEW
Last Name:HADDIX
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 1:23111 LORRAINE BLVD
Mailing Address - Street 2:APT 102
Mailing Address - City:BROWNSTOWN TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48183-3096
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29255 W JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:GIBRALTAR
Practice Address - State:MI
Practice Address - Zip Code:48173-9738
Practice Address - Country:US
Practice Address - Phone:734-675-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302032555183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist