Provider Demographics
NPI:1598193435
Name:COUILLARD, JENNIFER L (RPH)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:COUILLARD
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 1:1131 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:CHEBOYGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49721-2124
Mailing Address - Country:US
Mailing Address - Phone:231-627-7139
Mailing Address - Fax:231-627-5358
Practice Address - Street 1:1131 E STATE ST
Practice Address - Street 2:
Practice Address - City:CHEBOYGAN
Practice Address - State:MI
Practice Address - Zip Code:49721-2124
Practice Address - Country:US
Practice Address - Phone:231-627-7139
Practice Address - Fax:231-627-5358
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-30
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302028028183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist