Provider Demographics
NPI:1639619034
Name:JOHN, RENU (RPH)
Entity Type:Individual
Prefix:MR
First Name:RENU
Middle Name:
Last Name:JOHN
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 1:3410 E 12 MILE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2593
Mailing Address - Country:US
Mailing Address - Phone:800-231-8155
Mailing Address - Fax:800-848-0149
Practice Address - Street 1:3410 E 12 MILE RD
Practice Address - Street 2:SUITE A
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-2593
Practice Address - Country:US
Practice Address - Phone:800-231-8155
Practice Address - Fax:800-848-0149
Is Sole Proprietor?:No
Enumeration Date:2017-03-03
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302037079183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist