Provider Demographics
NPI:1376655373
Name:DAVISON DRUG STORE INC
Entity Type:Organization
Organization Name:DAVISON DRUG STORE INC
Other - Org Name:MEDICAP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ARNES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:810-658-2646
Mailing Address - Street 1:9070 DAVISON RD
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-1037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9070 DAVISON RD
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-1037
Practice Address - Country:US
Practice Address - Phone:810-658-2646
Practice Address - Fax:810-653-7819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
MI5301007144333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2360597OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MI4184739Medicaid
MI4184720Medicaid
MIBM6668252OtherDEA #
2360597OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MIOP38130Medicare PIN