Provider Demographics
NPI:1497924773
Name:PAGNUCCO, MARY LISA (RPH, PHARMD, BCACP)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LISA
Last Name:PAGNUCCO
Suffix:
Gender:F
Credentials:RPH, PHARMD, BCACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 MICHIGAN ST NE
Mailing Address - Street 2:PHYSICIAN ASSISTANT STUDIES, SUITE 164
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-3314
Mailing Address - Country:US
Mailing Address - Phone:616-331-5985
Mailing Address - Fax:
Practice Address - Street 1:301 MICHIGAN ST NE
Practice Address - Street 2:PHYSICIAN ASSISTANT STUDIES, SUITE 164
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3314
Practice Address - Country:US
Practice Address - Phone:616-331-5985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-21
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302028914183500000X
MEPR5980183500000X
MT6408183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist