Provider Demographics
NPI:1598350134
Name:SANJOSE, TRISHA ANNE (CPHT)
Entity Type:Individual
Prefix:
First Name:TRISHA
Middle Name:ANNE
Last Name:SANJOSE
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 N COLONIAL ST
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-1122
Mailing Address - Country:US
Mailing Address - Phone:616-638-4646
Mailing Address - Fax:616-667-9715
Practice Address - Street 1:4542 KENOWA AVE SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-9523
Practice Address - Country:US
Practice Address - Phone:616-667-9713
Practice Address - Fax:616-667-9715
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303009791183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician