Provider Demographics
NPI:1578645545
Name:FERNANDEZ, MANDA LOUISE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:MANDA
Middle Name:LOUISE
Last Name:FERNANDEZ
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 1:15755 PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-1193
Mailing Address - Country:US
Mailing Address - Phone:313-382-2338
Mailing Address - Fax:313-383-2577
Practice Address - Street 1:3390 WEST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183
Practice Address - Country:US
Practice Address - Phone:734-676-6622
Practice Address - Fax:734-676-4166
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025457183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302025457OtherPHARMACIST LICENSE NUMBER