Provider Demographics
NPI:1457985780
Name:VANWASSHENOVA, MICHAEL ALFRED (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALFRED
Last Name:VANWASSHENOVA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 S MONROE ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-1442
Mailing Address - Country:US
Mailing Address - Phone:734-384-9559
Mailing Address - Fax:734-384-5597
Practice Address - Street 1:919 S MONROE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-1442
Practice Address - Country:US
Practice Address - Phone:734-384-9559
Practice Address - Fax:734-384-5597
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302032982183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist