Provider Demographics
NPI:1619019957
Name:BELAVISTA DRUGS INC
Entity Type:Organization
Organization Name:BELAVISTA DRUGS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CHIEF PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JIHAD
Authorized Official - Middle Name:H
Authorized Official - Last Name:BEYDOUN
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:734-282-1940
Mailing Address - Street 1:15830 FORT ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-1367
Mailing Address - Country:US
Mailing Address - Phone:734-282-1940
Mailing Address - Fax:734-282-1539
Practice Address - Street 1:15830 FORT ST
Practice Address - Street 2:SUITE 5
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-1367
Practice Address - Country:US
Practice Address - Phone:734-282-1940
Practice Address - Fax:734-282-1539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010082253336C0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2367616Medicaid
5528900001Medicare UPIN
MI2367616Medicaid
5528900001Medicare NSC