Provider Demographics
NPI:1700922291
Name:THIBAULT, MICHAEL DENNIS (BS RPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DENNIS
Last Name:THIBAULT
Suffix:
Gender:M
Credentials:BS RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:82 MAPLETON RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-3615
Mailing Address - Country:US
Mailing Address - Phone:313-885-5679
Mailing Address - Fax:313-885-5679
Practice Address - Street 1:82 MAPLETON RD
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE FARMS
Practice Address - State:MI
Practice Address - Zip Code:48236-3615
Practice Address - Country:US
Practice Address - Phone:313-885-5679
Practice Address - Fax:313-885-5679
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302024848183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist