Provider Demographics
NPI:1629350848
Name:KOHLEY, DEIRDRE
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:
Last Name:KOHLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2484 WINCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441-3238
Mailing Address - Country:US
Mailing Address - Phone:231-755-1306
Mailing Address - Fax:
Practice Address - Street 1:2484 WINCHESTER DR
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-3238
Practice Address - Country:US
Practice Address - Phone:231-755-1306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302024229183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist