Provider Demographics
NPI:1609477769
Name:BRACKETT, MARIE L (BS)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:L
Last Name:BRACKETT
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4334 HAYES ST
Mailing Address - Street 2:
Mailing Address - City:COOPERSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49404-9662
Mailing Address - Country:US
Mailing Address - Phone:616-890-5974
Mailing Address - Fax:
Practice Address - Street 1:355 54TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49548-5614
Practice Address - Country:US
Practice Address - Phone:616-552-6226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025984183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist