Provider Demographics
NPI:1043257371
Name:LEBRYK, MICHAEL GERARD (RPH)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GERARD
Last Name:LEBRYK
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 1:20853 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1456
Mailing Address - Country:US
Mailing Address - Phone:313-881-4480
Mailing Address - Fax:313-881-7449
Practice Address - Street 1:20853 MACK AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-1456
Practice Address - Country:US
Practice Address - Phone:313-881-4480
Practice Address - Fax:313-881-7449
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302026288183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2348692OtherNABP
MI2740836Medicaid
MI2740836Medicaid