Provider Demographics
NPI:1396024279
Name:POPKE, JASON MICHAEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MICHAEL
Last Name:POPKE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 CLYDE PARK AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-9525
Mailing Address - Country:US
Mailing Address - Phone:616-531-9629
Mailing Address - Fax:
Practice Address - Street 1:5500 CLYDE PARK AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-9525
Practice Address - Country:US
Practice Address - Phone:616-531-9629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-10
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302037974183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist