Provider Demographics
NPI:1710977129
Name:DEXTER PHARMACY INC
Entity Type:Organization
Organization Name:DEXTER PHARMACY INC
Other - Org Name:VILLAGE PHARMACY II
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KNAAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-668-9600
Mailing Address - Street 1:325 N MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-2824
Mailing Address - Country:US
Mailing Address - Phone:734-668-9600
Mailing Address - Fax:734-668-9218
Practice Address - Street 1:325 N MAPLE RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-2824
Practice Address - Country:US
Practice Address - Phone:734-668-9600
Practice Address - Fax:734-668-9218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010067403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3446239Medicaid
MI2357982OtherNCPDP