Provider Demographics
NPI:1326661554
Name:MCDERMOTT, MICHEAL
Entity Type:Individual
Prefix:
First Name:MICHEAL
Middle Name:
Last Name:MCDERMOTT
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 1:428 N WASHINGTON ST APT 2
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-2859
Mailing Address - Country:US
Mailing Address - Phone:313-676-1319
Mailing Address - Fax:
Practice Address - Street 1:2170 WASHTENAW RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1744
Practice Address - Country:US
Practice Address - Phone:734-485-3899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303019471183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician