Provider Demographics
NPI:1740806298
Name:HANNAH, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:HANNAH
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 1:3126 CLAWSON AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-3013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:271 N GROESBECK HWY
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-1546
Practice Address - Country:US
Practice Address - Phone:586-333-5845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-21
Last Update Date:2020-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53024109971835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory CareGroup - Single Specialty