Provider Demographics
NPI:1518348325
Name:FITZGERALD, JEFFREY MICHAEL (RPH)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:JEFF
Other - Middle Name:M
Other - Last Name:FITZGERALD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:801 WILLOW HWY
Mailing Address - Street 2:
Mailing Address - City:GRAND LEDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48837-2009
Mailing Address - Country:US
Mailing Address - Phone:517-627-5384
Mailing Address - Fax:
Practice Address - Street 1:801 WILLOW HWY
Practice Address - Street 2:
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837-2009
Practice Address - Country:US
Practice Address - Phone:517-627-5384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302028015183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI183500000XMedicaid
MI183500000XMedicare Oscar/Certification
MI183500000XMedicare UPIN
MI183500000XMedicaid