Provider Demographics
NPI:1447365473
Name:DDM INC
Entity type:Organization
Organization Name:DDM INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:B
Authorized Official - Last Name:MAUPIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:231-943-0085
Mailing Address - Street 1:4025 CHURNS VILLAGE DR.
Mailing Address - Street 2:STE A.
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684
Mailing Address - Country:US
Mailing Address - Phone:231-943-0085
Mailing Address - Fax:231-943-0095
Practice Address - Street 1:4025 CHUMS VILLAGE DR
Practice Address - Street 2:STE A
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-6992
Practice Address - Country:US
Practice Address - Phone:231-943-0085
Practice Address - Fax:231-943-0095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301007598333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2364064Medicaid
2364064OtherOTHER ID NUMBER-COMMERCIAL NUMBER
2364064OtherOTHER ID NUMBER-COMMERCIAL NUMBER