Provider Demographics
NPI:1093443434
Name:FEWLESS, PATRICK THOMAS (RPH)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:THOMAS
Last Name:FEWLESS
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 1:521 BAYBERRY POINTE DR NW APT A
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-8009
Mailing Address - Country:US
Mailing Address - Phone:616-259-3753
Mailing Address - Fax:
Practice Address - Street 1:4365 LAKE MICHIGAN DR NW
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:MI
Practice Address - Zip Code:49534-4544
Practice Address - Country:US
Practice Address - Phone:616-791-1655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302414515183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist