Provider Demographics
NPI:1851957708
Name:FISK, REBECCA D (PHARMD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:D
Last Name:FISK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 LAFAYETTE AVE SE STE 2045
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4692
Mailing Address - Country:US
Mailing Address - Phone:616-685-3098
Mailing Address - Fax:616-685-3095
Practice Address - Street 1:300 LAFAYETTE AVE SE STE 2045
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4692
Practice Address - Country:US
Practice Address - Phone:616-685-3098
Practice Address - Fax:616-685-3095
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-16
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03438920183500000X
MI5602413548183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist