Provider Demographics
NPI:1194014076
Name:THIBODEAU, PAMELA (RPH)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:THIBODEAU
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 1:1020 E HILL RD
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-4803
Mailing Address - Country:US
Mailing Address - Phone:810-232-4111
Mailing Address - Fax:810-233-6360
Practice Address - Street 1:1020 E HILL RD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-4803
Practice Address - Country:US
Practice Address - Phone:810-232-4111
Practice Address - Fax:810-233-6360
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302027425183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist