Provider Demographics
NPI:1639561608
Name:PAPATRIANTAFYLLOU, FAWN
Entity Type:Individual
Prefix:
First Name:FAWN
Middle Name:
Last Name:PAPATRIANTAFYLLOU
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 1:300 E F ST
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-3442
Mailing Address - Country:US
Mailing Address - Phone:906-774-0563
Mailing Address - Fax:906-774-1186
Practice Address - Street 1:300 E F ST
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-3442
Practice Address - Country:US
Practice Address - Phone:906-774-0563
Practice Address - Fax:906-774-1186
Is Sole Proprietor?:No
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302039462183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist