Provider Demographics
NPI:1134597586
Name:DOMAN, JON PAUL (RPH)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:PAUL
Last Name:DOMAN
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 1:36567 GODDARD RD
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-1232
Mailing Address - Country:US
Mailing Address - Phone:734-941-0755
Mailing Address - Fax:734-941-8771
Practice Address - Street 1:36567 GODDARD RD
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-1232
Practice Address - Country:US
Practice Address - Phone:734-941-0755
Practice Address - Fax:734-941-8771
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-02
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302026267183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302026267OtherSTATE OF MICHIGAN DEPT OF LICENSING AND REGULATORY AFFAIRS