Provider Demographics
NPI:1083272702
Name:SPENCER, JEREMY L (PHARMD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:L
Last Name:SPENCER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 BENSON AVE NE APT 1315
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-0040
Mailing Address - Country:US
Mailing Address - Phone:231-872-0657
Mailing Address - Fax:
Practice Address - Street 1:2770 S STATE RD
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846-8472
Practice Address - Country:US
Practice Address - Phone:231-872-0657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020425161835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy