Provider Demographics
NPI:1467922054
Name:VERNOR PHARMACY PLLC
Entity Type:Organization
Organization Name:VERNOR PHARMACY PLLC
Other - Org Name:VERNOR PHARMACY PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMAD
Authorized Official - Middle Name:H
Authorized Official - Last Name:DAKDOUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-663-5858
Mailing Address - Street 1:7649 W VERNOR HWY
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48209-1513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2117 SPRINGWELLS ST STE B
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48209-1507
Practice Address - Country:US
Practice Address - Phone:313-395-2887
Practice Address - Fax:313-395-2889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-27
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5301011498Medicaid