Provider Demographics
NPI:1922768308
Name:BRONSON VILLAGE DRUG, INC.
Entity Type:Organization
Organization Name:BRONSON VILLAGE DRUG, INC.
Other - Org Name:COLON VILLAGE DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:STULL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:269-655-4402
Mailing Address - Street 1:25344 RED ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:MATTAWAN
Mailing Address - State:MI
Mailing Address - Zip Code:49071-9742
Mailing Address - Country:US
Mailing Address - Phone:269-655-4402
Mailing Address - Fax:
Practice Address - Street 1:131 S BLACKSTONE AVE
Practice Address - Street 2:
Practice Address - City:COLON
Practice Address - State:MI
Practice Address - Zip Code:49040-9398
Practice Address - Country:US
Practice Address - Phone:269-432-3435
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-27
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5301007449OtherPHARMACY LICENSE