Provider Demographics
NPI:1457815565
Name:ISIDRO II INC
Entity Type:Organization
Organization Name:ISIDRO II INC
Other - Org Name:UNIVERSITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:CHRISTINA
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-812-9129
Mailing Address - Street 1:PO BOX 871819
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-7519
Mailing Address - Country:US
Mailing Address - Phone:734-812-9129
Mailing Address - Fax:734-629-1717
Practice Address - Street 1:7288 N SHELDON RD STE A
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2150
Practice Address - Country:US
Practice Address - Phone:734-812-9129
Practice Address - Fax:734-629-1717
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ISIDRO II, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-23
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P60030OtherPTAN
200810OtherDSME/ DPP
MI1295918274Medicaid
MI0P57520OtherMASS IMMUNIZATION
MI1740306778OtherRPH NPI