Provider Demographics
NPI:1720372584
Name:FEDORIW, MYRON
Entity Type:Individual
Prefix:
First Name:MYRON
Middle Name:
Last Name:FEDORIW
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 1:32001 JOHN R RD
Mailing Address - Street 2:T-0282
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-1322
Mailing Address - Country:US
Mailing Address - Phone:248-585-4716
Mailing Address - Fax:248-585-4716
Practice Address - Street 1:32001 JOHN R RD
Practice Address - Street 2:T-0282
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-1322
Practice Address - Country:US
Practice Address - Phone:248-585-4716
Practice Address - Fax:248-585-4716
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302021842183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist