Provider Demographics
NPI:1467741660
Name:ENNESSER, DONALD J
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:J
Last Name:ENNESSER
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 1:6535 PAW PAW AVE
Mailing Address - Street 2:
Mailing Address - City:COLOMA
Mailing Address - State:MI
Mailing Address - Zip Code:49038-8805
Mailing Address - Country:US
Mailing Address - Phone:269-468-3858
Mailing Address - Fax:
Practice Address - Street 1:6535 PAW PAW AVE
Practice Address - Street 2:
Practice Address - City:COLOMA
Practice Address - State:MI
Practice Address - Zip Code:49038-8805
Practice Address - Country:US
Practice Address - Phone:269-468-3858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-29
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302026086183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist