Provider Demographics
NPI:1801015748
Name:REGAN, ROBERT J (RPH)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:REGAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3026 W GRAND BLVD
Mailing Address - Street 2:SUITE 11-400
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-6021
Mailing Address - Country:US
Mailing Address - Phone:313-456-0470
Mailing Address - Fax:
Practice Address - Street 1:3026 W GRAND BLVD
Practice Address - Street 2:SUITE 11-400
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-6021
Practice Address - Country:US
Practice Address - Phone:313-456-0470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302024065183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist