Provider Demographics
NPI:1720202146
Name:HYDE, VICKI (RPH)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:HYDE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 E STATE HIGHWAY M35
Mailing Address - Street 2:
Mailing Address - City:GWINN
Mailing Address - State:MI
Mailing Address - Zip Code:49841-9159
Mailing Address - Country:US
Mailing Address - Phone:906-346-0104
Mailing Address - Fax:906-346-3340
Practice Address - Street 1:130 E STATE HIGHWAY M35
Practice Address - Street 2:
Practice Address - City:GWINN
Practice Address - State:MI
Practice Address - Zip Code:49841
Practice Address - Country:US
Practice Address - Phone:906-346-0104
Practice Address - Fax:906-346-6422
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302032831183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist