Provider Demographics
NPI:1831289198
Name:GOLL, RENEE M (RPH)
Entity Type:Individual
Prefix:MS
First Name:RENEE
Middle Name:M
Last Name:GOLL
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 1:31223 MUNGER ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-3205
Mailing Address - Country:US
Mailing Address - Phone:734-513-3802
Mailing Address - Fax:
Practice Address - Street 1:34500 FORD RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-3090
Practice Address - Country:US
Practice Address - Phone:734-729-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302027832183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302027832Other5302027832