Provider Demographics
NPI:1982272324
Name:BEVIS, SEAN
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:BEVIS
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 1:20518 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-3105
Mailing Address - Country:US
Mailing Address - Phone:586-265-3862
Mailing Address - Fax:
Practice Address - Street 1:18430 FENKELL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-2301
Practice Address - Country:US
Practice Address - Phone:313-837-2340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-13
Last Update Date:2021-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303035105183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician