Provider Demographics
NPI:1790069755
Name:KING, JOELLEN FAY (RPH)
Entity Type:Individual
Prefix:
First Name:JOELLEN
Middle Name:FAY
Last Name:KING
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 N BRIGGS RD
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MI
Mailing Address - Zip Code:49082-9506
Mailing Address - Country:US
Mailing Address - Phone:517-639-3253
Mailing Address - Fax:
Practice Address - Street 1:410 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-1139
Practice Address - Country:US
Practice Address - Phone:517-279-1230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302027247183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist