Provider Demographics
NPI:1780119131
Name:CORY, DOUGLAS ROLAND
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:ROLAND
Last Name:CORY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12743 STRAIT RD
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MI
Mailing Address - Zip Code:49241-9742
Mailing Address - Country:US
Mailing Address - Phone:517-392-5269
Mailing Address - Fax:
Practice Address - Street 1:12743 STRAIT RD
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:MI
Practice Address - Zip Code:49241-9742
Practice Address - Country:US
Practice Address - Phone:517-392-5269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302042510390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302042510OtherPHARMACY INTERN LICENSE
MI1209579OtherNATIONAL ASSOCIATION OF BOARDS OF PHARMACY (NABP) NUMBER