Provider Demographics
NPI:1750688784
Name:BIG D CORP
Entity type:Organization
Organization Name:BIG D CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DYTRI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-598-4650
Mailing Address - Street 1:C/O CHRISTOPHER PENCAK PC
Mailing Address - Street 2:27322 23 MILE RD. STE. 7
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48051
Mailing Address - Country:US
Mailing Address - Phone:586-598-4650
Mailing Address - Fax:586-598-4651
Practice Address - Street 1:19460 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-1200
Practice Address - Country:US
Practice Address - Phone:313-533-0560
Practice Address - Fax:313-533-0568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-28
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010095183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2375207OtherNCPDP PROVIDER IDENTIFICATION NUMBER