Provider Demographics
NPI:1376833558
Name:SLATTERY, PATRICK TIMOTHY
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:TIMOTHY
Last Name:SLATTERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3364 HORRELL CT
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-1099
Mailing Address - Country:US
Mailing Address - Phone:818-714-5816
Mailing Address - Fax:
Practice Address - Street 1:G4007 S SAGINAW ST
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48529-1617
Practice Address - Country:US
Practice Address - Phone:810-742-7002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-09
Last Update Date:2011-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302022194183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist