Provider Demographics
NPI:1437107448
Name:PROFESSIONAL VILLAGE PHARMACY
Entity Type:Organization
Organization Name:PROFESSIONAL VILLAGE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BICKING
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:734-243-5656
Mailing Address - Street 1:128 COLE RD STE B
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-4104
Mailing Address - Country:US
Mailing Address - Phone:734-457-2211
Mailing Address - Fax:734-457-3738
Practice Address - Street 1:128 COLE RD STE B
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-4104
Practice Address - Country:US
Practice Address - Phone:734-457-2211
Practice Address - Fax:734-457-3738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301006995310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4103884Medicaid
MI4103884Medicaid