Provider Demographics
NPI:1710010731
Name:COLLINS, GWENESIA S (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:GWENESIA
Middle Name:S
Last Name:COLLINS
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17060 MASONIC STE 107
Mailing Address - Street 2:
Mailing Address - City:FRASER
Mailing Address - State:MI
Mailing Address - Zip Code:48026-2561
Mailing Address - Country:US
Mailing Address - Phone:586-293-0500
Mailing Address - Fax:586-293-0501
Practice Address - Street 1:17060 MASONIC
Practice Address - Street 2:SUITE 107
Practice Address - City:FRASER
Practice Address - State:MI
Practice Address - Zip Code:48026-2561
Practice Address - Country:US
Practice Address - Phone:586-293-0500
Practice Address - Fax:586-293-0501
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301008165183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI01882OtherBCBS PROVIDER ID
MI01809OtherBCBS DME PROVIDER ID
MI2367363Medicaid
MI2367363Medicaid