Provider Demographics
NPI:1659492783
Name:BECKER, DAVID JASON
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JASON
Last Name:BECKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2942 AMBASSADOR CT
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-1851
Mailing Address - Country:US
Mailing Address - Phone:248-943-4759
Mailing Address - Fax:
Practice Address - Street 1:2942 AMBASSADOR CT
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-1851
Practice Address - Country:US
Practice Address - Phone:248-943-4759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302030357183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist