Provider Demographics
NPI:1568664761
Name:MITCH, DEBRA (RPH)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:MITCH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12461 US ROUTE 24
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:OH
Mailing Address - Zip Code:43522-9604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12461 US ROUTE 24
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:OH
Practice Address - Zip Code:43522-9604
Practice Address - Country:US
Practice Address - Phone:419-832-3472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03212806183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist