Provider Demographics
NPI:1548326911
Name:DIDUR, GEORGE STEHPEN (RPH)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:STEHPEN
Last Name:DIDUR
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3820 S HADLEY RD
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48462-9115
Mailing Address - Country:US
Mailing Address - Phone:248-627-3116
Mailing Address - Fax:
Practice Address - Street 1:5751 CLARKSTON RD
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48348
Practice Address - Country:US
Practice Address - Phone:248-625-1015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025263183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302025263OtherREGISTERED PHARMACIST LIC