Provider Demographics
NPI:1407436256
Name:FLEGEL, REBECCA MARIE
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MARIE
Last Name:FLEGEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 S TRENT RD
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:MI
Mailing Address - Zip Code:49451-9715
Mailing Address - Country:US
Mailing Address - Phone:231-286-2718
Mailing Address - Fax:616-784-2454
Practice Address - Street 1:1535 S TRENT RD
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:MI
Practice Address - Zip Code:49451-9715
Practice Address - Country:US
Practice Address - Phone:231-286-2718
Practice Address - Fax:616-784-2454
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303000770183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician