Provider Demographics
NPI:1538512819
Name:ROELANDT, JENNY LUELLA
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:LUELLA
Last Name:ROELANDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 PINE DR
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48462-9272
Mailing Address - Country:US
Mailing Address - Phone:248-240-4513
Mailing Address - Fax:
Practice Address - Street 1:10 S ORTONVILLE RD
Practice Address - Street 2:
Practice Address - City:ORTONVILLE
Practice Address - State:MI
Practice Address - Zip Code:48462-8818
Practice Address - Country:US
Practice Address - Phone:248-627-2888
Practice Address - Fax:248-627-1218
Is Sole Proprietor?:No
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302042387183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist