Provider Demographics
NPI:1023106705
Name:CANVASSER, CHARLES M (RPH)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:M
Last Name:CANVASSER
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 1:7343 VILLAGE SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3384
Mailing Address - Country:US
Mailing Address - Phone:248-788-0298
Mailing Address - Fax:
Practice Address - Street 1:34500 FORD RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-3090
Practice Address - Country:US
Practice Address - Phone:734-729-2200
Practice Address - Fax:734-729-3857
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302024145183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2940800Medicaid
MI0479790001Medicare ID - Type Unspecified