Provider Demographics
NPI:1801013750
Name:JIMMERSON, MARCELLA (RPH)
Entity Type:Individual
Prefix:MRS
First Name:MARCELLA
Middle Name:
Last Name:JIMMERSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:MARCELLA
Other - Middle Name:JIMMERSON
Other - Last Name:FLOURNOY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:3029 POWHATTAN PKWY
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-3740
Mailing Address - Country:US
Mailing Address - Phone:419-472-3494
Mailing Address - Fax:419-472-3494
Practice Address - Street 1:507 S TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-1613
Practice Address - Country:US
Practice Address - Phone:734-243-6700
Practice Address - Fax:734-242-2112
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302027998183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist