Provider Demographics
NPI:1235762907
Name:DENNIS, JEFFREY ALAN (RPH)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ALAN
Last Name:DENNIS
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 1:119 N ROLAND ST
Mailing Address - Street 2:
Mailing Address - City:MC BAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49657-9683
Mailing Address - Country:US
Mailing Address - Phone:231-825-8175
Mailing Address - Fax:231-825-8130
Practice Address - Street 1:119 N ROLAND ST
Practice Address - Street 2:
Practice Address - City:MC BAIN
Practice Address - State:MI
Practice Address - Zip Code:49657-9683
Practice Address - Country:US
Practice Address - Phone:231-825-8175
Practice Address - Fax:231-825-8130
Is Sole Proprietor?:No
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302028882183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist