Provider Demographics
NPI:1528404159
Name:BRISTOL, JOSEPH THOMAS (RPH)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:THOMAS
Last Name:BRISTOL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12441 STAFFORD RD
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:MI
Mailing Address - Zip Code:49451-9783
Mailing Address - Country:US
Mailing Address - Phone:231-853-2261
Mailing Address - Fax:231-853-6623
Practice Address - Street 1:12441 STAFFORD RD
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:MI
Practice Address - Zip Code:49451-9783
Practice Address - Country:US
Practice Address - Phone:231-853-2261
Practice Address - Fax:231-853-6623
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-22
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302022974183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist