Provider Demographics
NPI:1447743109
Name:JAIN, SANJAY SURESHCHANDRA
Entity Type:Individual
Prefix:
First Name:SANJAY
Middle Name:SURESHCHANDRA
Last Name:JAIN
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 1:2019 FOX HILL DR APT 6
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-5206
Mailing Address - Country:US
Mailing Address - Phone:248-773-6236
Mailing Address - Fax:
Practice Address - Street 1:11801 N SAGINAW ST
Practice Address - Street 2:
Practice Address - City:MOUNT MORRIS
Practice Address - State:MI
Practice Address - Zip Code:48458-1503
Practice Address - Country:US
Practice Address - Phone:810-686-7106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302040189183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist