Provider Demographics
NPI:1295918274
Name:ISIDRO II INC
Entity type:Organization
Organization Name:ISIDRO II INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRES, PIC
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:734-812-9129
Mailing Address - Street 1:PO BOX 871819
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-7519
Mailing Address - Country:US
Mailing Address - Phone:734-812-9129
Mailing Address - Fax:734-629-1717
Practice Address - Street 1:7288 N SHELDON RD STE A
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2150
Practice Address - Country:US
Practice Address - Phone:734-812-9129
Practice Address - Fax:734-629-1717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332900000X, 332B00000X, 333600000X, 3336C0002X
MI53010084063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332900000XSuppliersNon-Pharmacy Dispensing Site
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1982884318Medicaid
2043557OtherPK
MI0P57520OtherPTAN
MI0P60030OtherMASS IMMUNIZATION
MI1295918274Medicaid