Provider Demographics
NPI:1114957081
Name:PARKS, JENNIFER SUSAN (RPH)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:SUSAN
Last Name:PARKS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49094-1154
Mailing Address - Country:US
Mailing Address - Phone:517-741-3604
Mailing Address - Fax:517-741-7812
Practice Address - Street 1:206 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:MI
Practice Address - Zip Code:49094-1154
Practice Address - Country:US
Practice Address - Phone:517-741-3604
Practice Address - Fax:517-741-7812
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302031878183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist