Provider Demographics
NPI:1639269749
Name:FURUTA, CLYDE (RPH)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:
Last Name:FURUTA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23247 PINEWOOD ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-4754
Mailing Address - Country:US
Mailing Address - Phone:877-899-6337
Mailing Address - Fax:877-899-6360
Practice Address - Street 1:23247 PINEWOOD ST
Practice Address - Street 2:SUITE B
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-4754
Practice Address - Country:US
Practice Address - Phone:877-899-6337
Practice Address - Fax:877-899-6360
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302023127183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist