Provider Demographics
NPI:1346908449
Name:MONAGHAN, TREVOR JORDAN (CPT)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:JORDAN
Last Name:MONAGHAN
Suffix:
Gender:M
Credentials:CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-3850
Mailing Address - Country:US
Mailing Address - Phone:517-782-9382
Mailing Address - Fax:
Practice Address - Street 1:3100 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3850
Practice Address - Country:US
Practice Address - Phone:517-782-9382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI571692183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician