Provider Demographics
NPI:1053890160
Name:TANDEL, PANKAJKUMAR
Entity type:Individual
Prefix:
First Name:PANKAJKUMAR
Middle Name:
Last Name:TANDEL
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 1:42086 GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1643
Mailing Address - Country:US
Mailing Address - Phone:586-554-2745
Mailing Address - Fax:586-554-2746
Practice Address - Street 1:42086 GARFIELD RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1643
Practice Address - Country:US
Practice Address - Phone:586-554-2745
Practice Address - Fax:586-554-2746
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302039238183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1043629488Medicaid