Provider Demographics
NPI:1720369929
Name:GILLICH, STEPHEN ERIC (RPH)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:ERIC
Last Name:GILLICH
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 1:8364 BYRON CENTER AVE SW
Mailing Address - Street 2:
Mailing Address - City:BYRON CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49315-8957
Mailing Address - Country:US
Mailing Address - Phone:616-878-0497
Mailing Address - Fax:616-878-0573
Practice Address - Street 1:8364 BYRON CENTER AVE SW
Practice Address - Street 2:
Practice Address - City:BYRON CENTER
Practice Address - State:MI
Practice Address - Zip Code:49315-8957
Practice Address - Country:US
Practice Address - Phone:616-878-0497
Practice Address - Fax:616-878-0573
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302031860183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist