Provider Demographics
NPI:1407127905
Name:STIVER, JOLENE LESSARD (RPH)
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:LESSARD
Last Name:STIVER
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 1:20784 DIAMOND SHORES DR
Mailing Address - Street 2:
Mailing Address - City:CASSOPOLIS
Mailing Address - State:MI
Mailing Address - Zip Code:49031-9386
Mailing Address - Country:US
Mailing Address - Phone:269-445-3764
Mailing Address - Fax:
Practice Address - Street 1:301 S US HIGHWAY 131
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-8833
Practice Address - Country:US
Practice Address - Phone:269-279-9066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-16
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302035415183500000X
IN26091598A183500000X
MN111890183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist